Strategies for Changing Current Contraceptive Education Methods

Implementing Structured Contraception Counseling to Increase the Contraception Knowledge of Women of Childbearing Age Seen in a Private Obstetrics and Gynecology Clinic: A Quality Improvement Project

Abstract

This is an evidence-based project that is aimed implementing a structured contraceptive counseling at our clinical setting. The number of unintended pregnancies that have been reported at our clinic have been on the rise lately, and this is a great concern since it puts pressure on the women and their families. We have analyzed several studies and they all point to the fact that structured contraceptive counseling is beneficial to the providers and to the clients. By using structured contraceptive counseling, it is possible to increase the knowledge of women on contraceptive, which is currently lacking within our clinical setting. The contraceptive counseling being conducted at out clinic is not structured and some of the providers tend to forget what they taught the client, which results in the client not receiving the appropriate information. Having a structured contraceptive counseling has been shown to be more effective and offers the client an opportunity to ask questions and seek clarification for what they did not understand. This paper is aims to demonstrate the efficacy of using a structured contraceptive counseling method and the benefits that will be gained from using such a method. As shown in our literature review, there are numerous methods that a clinic can adopt that are all aimed at implementing a structured education method. We have made recommendations based on our analysis and we recommend that the clinic implement audio-visual and shared decision-making methods.

Section One: Introduction and Overview of the Problem

A wide variety of contraceptive methods are available in the United states for women to select in order to prevent or reduce the number of unwanted pregnancies. However, the number of unintended pregnancy rates have remained high and it is estimated that approximately 49% of pregnancies within a year are unintended. The number of unintended pregnancies is most high amongst women who are aged

The high frequency of unintended pregnancy is mainly associated with nonuse of contraceptive methods, incorrect and inconsistent use of methods, and use of less effective methods. The disparities in unintended pregnancy are also contributed to by racial and ethnic differences in the use of contraceptive methods. The lack of knowledge and failure to understand or remember what has been taught regarding contraceptive usage is also a contributor of unintended pregnancy. The increase in unintended pregnancy rates results in an increase in the terminations rates, which currently stand at 47% at the clinic (Zapata et al., 2015). The number of women who present to their healthcare providers with unintended pregnancies has continued to be high (Abdel-Tawab & Roter, 2002). A majority of the women state that if they had known more about contraceptives they would have prevented the pregnancy. Many of the women have indicated they would have used a contraceptive method if they had the information (Dehlendorf, Kimport, Levy, & Steinauer, 2014). However, the information that most women receive form their healthcare providers in regards to contraceptives is insufficient and inconsistent. The impact that the information has on a woman\\\\\\\'s choice of contraception is determined by age, preference, and recommendation by the healthcare provider (Culwell & Adams Hillard, 2008). It has been noted that a majority of the contraceptive methods that women choose is influenced by provider counseling. Therefore, there is evidence that most women are listening to the advice they receive from their providers, but they must be finding it hard to recall what the provider advised or taught them on the contraceptive method. Without proper information women are left to figure contraceptives out for themselves and this results in usage problems as reported by the women who visit the clinic.

At the Obstetrics (OB) and gynecology (GYN) clinic there are four healthcare providers who provide their own versions of contraceptive education and counseling. There is no standard method that is employed for delivery of education. Without a standardized method of contraceptive education delivery, there are some conflicting information that could be confusing the women who visit the clinic. Some the providers have a preference to a particular type of contraceptive (Dehlendorf, Kimport, et al., 2014), which they will advocate for irrespective of the desires of the women. This could result in failure by the women to follow the guidelines for using the contraceptive since they feel they do not like or understand the method. Contraceptive method selection should be done with the client and after they have understood the different methods available. Education should be targeted to instill knowledge and not just to push for a particular method (Dehlendorf, Levy, Kelley, Grumbach, & Steinauer, 2013). If there could be a standardized method of delivering education, the four healthcare providers would be offering the same information to the women and this would increase the retention rate for the information being taught. With diverse information being provided the women get confused and they end up not understanding or remembering how and when to use contraceptives.

It is for this reason that we are seeking to implement a method for contraceptive education that will assist in preventing the negative patient outcomes that are being experienced at the clinic. The method to be implemented will provide an effective method for increasing the patients’ contraceptive knowledge in the hopes that the education will increase their usage of contraceptives (Dehlendorf et al., 2013). With a better approach to contraceptive education patients will be more comfortable and there might be interactive sessions so that the patients can ask questions (Culwell & Adams Hillard, 2008). This would reinforce the education and they are likely to remember what they learn and apply the knowledge to reduce cases of unintended pregnancies.

Reducing the rates of unintended pregnancies due to a lack of knowledge regarding the use of contraceptive is what we intend to reduce with this project. Delivering contraceptive education in a manner that is suitable for the women who visit the clinic and ensuring that the four healthcare providers are offering the same education in the prescribed manner will definitely have a positive outcome on the population served by the clinic. Any reduction in the rates of unintended pregnancies is beneficial not only for the clinic, but also for the women (Culwell & Adams Hillard, 2008; Dehlendorf, Tharayil, et al., 2014). The project aims to implement a structured education system that will be used for the delivery of contraceptive education. Using the structured education method will allow the healthcare providers to better disseminate information and there will be uniformity of the information being delivered to the patients (Moos, Bartholomew, & Lohr, 2003). Offering advice and recommendations that are backed with evidence, will be vital and helpful to the patients since the proposed contraceptive method would be suitable and in line with the patient\\\\\\\'s need or desire.

In 2016, the clinic reported 76 out of 1,000 women had an unintended pregnancy. This is 30% higher than the national average for the country. Seeing at how high the figure is, there is need to look for interventions that will assist in reducing the numbers. It has been earlier established that contraceptive counseling can be quite effective in reducing the rate of unintended pregnancy. However, even after the clinic adopted a contraceptive counseling the rates have not reduced as expected. It has been discovered that there is further need to have structured education on contraceptive. This would ensure that the healthcare providers follow the same procedures and educate the patients using the same methods. A majority of the patients who visit the clinic with unintended pregnancy have stated they were not aware of contraceptives and the ones who were aware seemed to have misunderstood the instructions. In order for contraceptive to be effective, there is need to use the contraceptive as expected or as recommended for it to be effective. Therefore, for the clinic to reduce the rate of unintended pregnancy it should adopt the strategies being proposed and have identical knowledge being given to the patients by the providers.

Our PICOT question is \\\\\\\"What methods of contraceptive counseling are shown to improve patients’ retention of contraceptive knowledge.\\\\\\\" It is our intention to increase the retention capability of the patients and we need to establish the best methods that we could employ. Analyzing what other researchers have noted to be effective in retention of knowledge will enable us to come up with strategies that we can implement in our setting and have a change in practice that is backed by evidence. Our target is to change the current practice where the different healthcare providers offer contraceptive education that is not structured and some of them do not recall what they recommended or suggested to a patient. Having a structured way of delivering education to the patients will ensure that one can be certain they have passed on the requisite information and they have checked to ensure that the patient understands what they have been taught or advised. Inconsistency of teaching means that some information may be omitted unintentionally if the healthcare provider fails to recall the information.

In conclusion, it is vital that the rates of unintended pregnancies be reduced, which would be beneficial to the women served by the clinic. Providing the women with accurate information regarding contraception will result in positive outcomes for the clinic and will reduce the rate of unintended pregnancies. The lack of knowledge has been identified as the main cause of the high rates, and considering that the clinic offers educational programs for the women then there is need to ensure that the information passed is well understood and adhered to by the women (Dehlendorf, Tharayil, et al., 2014; Moos et al., 2003). The best way is to increase the retention rate for the women. We aim to have a structured method for ensuring that the healthcare providers are able to deliver the same information to the patients, without having left out some information.

Section Two: Review of Literature/Synthesis of Literature

In order to identify the appropriate literature, we made use of numerous search strategies all aimed at answering our PICOT question. To maximize the likelihood of obtaining a coherent body of evidence, especially in relation to structured education on contraceptive methods, we only included articles that made use of data that was collected after 2009. Our search strategies were aimed at identifying all research covering structured contraceptive counseling approaches in clinical settings targeted towards improving knowledge and retention of the knowledge. We carried out our search using these four database search engines Ovid SP, PubMed, CINAHL, and Cochrane Library. Initially, we started by searching for contraceptive counseling aimed at increasing knowledge retention amongst women, but we found there were many irrelevant or redundant results. The searches resulted in a large number of articles discussing mostly the prevalence of unintended pregnancies and high rates of abortion. This was not the focus of our review. Eventually we decided to narrow down and search using the phrase structured contraceptive counseling. This narrowed down the results and we were able to select the required 5 articles for conducting our literature review. Not all the databases contained the relevant articles that we were seeking, but by making a combination of the four we were able to narrow down and identify the most appropriate articles for supporting our DNP project. With an aim of improving quality within our clinical setting, it was vital that we seek data and information from relevant and appropriate articles that demonstrate the importance of using different strategies for conducting contraceptive education.

The titles and abstracts of the initially identified articles were analyzed in order determine the articles to include and the ones to exclude based on our eligibility criteria. Abstracts that suggested experimental and cohort designs, qualitative methodology, or cross-sectional data were advanced for full article review. However, even after this abstract review we found we had to drill down further and eliminate more articles in order have our agreed number of 5 articles. Therefore, there was need for further review of the abstracts and article to select only the final articles for usage.

Literature Review

Structured counseling is designed to prevent unintended pregnancy. Making use of a structure will allow the client to visualize and understand the information that is being presented in order for them to progress through the stages towards making an informed choice of contraceptive method. According to Farrokh?Eslamlou et al. (2014), structured counseling is standardized in that the client will receive tailored and well-structured information on the use, effectiveness, and side effects of contraceptive methods. This is supported by Dehlendorf, Krajewski, and Borrero (2014), who also posits that structured counseling has been shown to be more effective than normal contraceptive counseling. Communicating the side effects that a particular contraceptive method would have on the client will ensure that the client understands the risks and knows what might go wrong. Dehlendorf, Krajewski, et al. (2014) showed that 37% of the women who choose to use hormonal IUD were not aware that there is a likelihood of them experiencing irregular bleeding. This demonstrates that the women were not properly educated on the contraceptive method that they selected. However, if the women had undergone structured counseling they would have been able to know of the side effects of the contraceptive method and they might have opted to use a method they are more comfortable with (Dehlendorf, Tharayil, et al., 2014). Using structured counseling within a clinical setting will offer the clients an opportunity for them to interact with the healthcare provider. Asking questions is a key component for structured counseling. Allowing the clients to ask questions will ensure that they understand what they are learning and they can be better informed. Questions are a way for making clarification and this has been proven to be quite effective in increasing knowledge of the clients (Secura, Allsworth, Madden, Mullersman, & Peipert, 2010). They are more likely to remember what they have learnt when they are given the chance to ask questions. Using structured counseling is not only beneficial to the client, but also for the healthcare providers. Providers who use a structured process they are more likely to provide complete information, promote compliance, and improve their performance by reducing guesswork. (Farrokh?Eslamlou et al., 2014)

Madden, Mullersman, Omvig, Secura, and Peipert (2013) also made use of structured contraceptive counseling. The difference in this study was that a majority of the research team members did not have any formal healthcare training. The study demonstrates that even non-healthcare providers can be effective in delivering contraceptive education if there is a structured method for delivering the education. The study participants were able to select from different contraceptive methods and they understood the methods they were selecting. This study supports what Farrokh?Eslamlou et al. (2014) posits that structured counseling is more effective in ensuring adherence and retention of knowledge amongst women as compared to other methods of contraceptive counseling. Both studies had a success rate of 89% when the providers made use of structured counseling.

Visual aids have been the most used educational methods for conducting contraceptive counseling sessions. Dehlendorf, Krajewski, et al. (2014) established that using audio-visual aids was more effective in increasing the understanding of women and knowledge retention as compared to using oral communication. Langston, Rosario, and Westhoff (2010) also established that there was increased usage of contraceptive and continuation of effective contraceptive methods when the clients are educated using audio-visual method. Making use of audio-visual training methods allows the client to both visualize and hear the information that is being presented (Hersh et al., 2017). Combining the two methods allows the client to better understand what they are being taught especially in regards to contraceptive methods and retention of the knowledge. Langston et al. (2010) indicates that 54% of the women who participated in their study were able to select an effective contraceptive method after they underwent the contraceptive education. Visual aids allow the healthcare provider to communicate the efficacy of contraceptive in a meaningful manner. Understanding the efficacy of contraceptive might not be the vital factor that drives method selection, but it has some impact on the method chosen by the client. There is no better way to communicate the side effects of a contraceptive method that by using visual aids. This will ensure that the client is better informed and they can make better selection of the method they would prefer. As has been noted by (Yee & Simon, 2010)communicating about the effectiveness of contraceptive in an informative and meaning way to the clients is critical. The rate of contraceptive knowledge has been shown to increase after the client has been taught using audio-visual methods (Dehlendorf, Krajewski, et al., 2014; Langston et al., 2010). When the clients were asked knowledge questions after the contraceptive education a majority of them demonstrated better understanding of contraceptive methods. On their next visit to the clinic, the clients seemed to recall more information regarding contraceptive. There was a 78% increase in the number of women who retained the information they were taught. The pre-test and post-test scores indicated that 85% of the women had a better understanding of contraceptive methods than when they first enrolled in the class (Secura et al., 2010).

The WHO has developed a structured counseling intervention called the Decision-Making Tool (DMT) that is used for family planning providers and clients. DMT is designed to increase the quality of care offered by improving the counseling process by using better client-provider interactions, providing accurate information, and increase informed choice. Essentially, the DMT is a two-sided flip chart that can be used by providers to educate their clients on family planning (Farrokh?Eslamlou et al., 2014). The double-sided flip chart has a side for the client and the other side for the provider (Langston et al., 2010). The client side assist the client in their decision-making and the provider side aids them in the counseling process. This tool has been shown to increase and improve communication with clients. The overall decision-making score for the clients increased from 22.5 to 27.6 (p

The concept of shared decision-making has been an increasing focus in health communication. Shared decision-making lies between two poles of directive counseling and informed choice. Looking at this model each party is recognized for having relevant expertise with the patient being the expert regarding her values and preferences and the healthcare provider having superior knowledge regarding medical information (Dehlendorf, Krajewski, et al., 2014). Using this model has been shown to be effective in increasing the knowledge of women on contraception by almost 79%. This approach is rarely used with one study indicating that the approach was used in less than a quarter of the visits. a majority of providers preferred using the informed choice approach or the foreclosed approach, which is what most providers use. According to Dehlendorf, Kimport, et al. (2014), in their qualitative study, women reported that receiving counseling with elements of shared decision-making was consistent with their personal preferences for family planning. Other studies have also supported this approach with many of them reporting positive effects especially in regards to the increased use of effective contraception. The knowledge that women acquired when they participated in counseling that had elements of shared decision-making also increased.

Appraisal of Evidence

The process of systematically and carefully assessing the outcome of scientific research in order to judge it trustworthiness, relevance, and value in a particular context is referred to as critical appraisal. Critical appraisal will look at the way a study has been conducted and will examine factors like internal validity, relevance, and generalizability. Critical appraisal allows clinicians to make use of research evidence reliably and efficiently. It is intended to enhance the healthcare professionals’ skills in determining if research evidence is true and relevant for her patients.

RAPID Critical Appraisal of the Langston et al. (2010) Study

The results of this study are valid since this was a randomized control trial of 222 women who were seeking a first trimester procedure for a spontaneous or induced abortion. Since this was not a review paper, there is no search strategy that has been provided and there was no need to have a search strategy. The validity of the study has been provided by the researchers using their own internal process in order to engage in research, which does not list validity processes explicitly. The results obtained from the study are not consistent to other studies because the researchers were only interested in women who were seeking a first trimester contraceptive procedure. The study results indicate that 54% of all participants chose a very effective method. Women in the intervention group were no more likely to choose a very effective method (OR 0.74, 95% CI 0.44, 1.26) or to initiate their method compared to the usual care group (OR 0.65, 95% CI 0.31, 1.34). In multivariate models, structured counseling was not associated with using a very effective method at 3 months (AOR 1.06, 95% CI 0.53, 2.14). Thus, little to no significant difference was seen in the study. The study had a confidence interval of 95%, which is statistically significant.

In regards to our current practice change, the participants of the study are similar to the ones in our setting, but the effects might not be similar since the study was limited in its outcomes. It is for this reason that it would not be feasible to implement the findings of this study in our practice setting. The clinically important outcomes for the study were considered and this led to the conclusion that while counseling is important it ought to be individualized to the patient. However, the preferences for my patients cannot be analyzed since the study outcomes are limited and my patients would prefer to have an option that is affordable and easy to use because they are likely to forget.

RAPID Critical Appraisal of the Madden et al. (2013) Study

This study was a prospective cohort study of 10,000 women 14-45 years who want to avoid pregnancy for at least 1 year and are initiating a new form of reversible contraception. The validity of the study has not explicitly listed, but the study does make use of its own internal process to guarantee validity. The study results are there were 6,530 (86%) women who enrolled into CHOICE at our university site and 1,107 (14%) women who enrolled at partner clinics. Uptake of long-acting reversible contraception was high at both the university site and partner clinics (72% and 78%, respectively, p

Implementing the study results would not be feasible for my practice setting mainly because the outcomes are not clear or related to implementing structured contraceptive counseling. All of the clinically important outcomes were considered in the study, and the conclusion was that counseling can be conducted by anyone provided they are given the appropriate structured educational materials. Although the study treatment would be applicable to my patients since they would prefer a reversible and highly effective contraceptive method, the study was not targeted towards structured contraceptive counseling.

RAPID Critical Appraisal of the Dehlendorf, Krajewski, et al. (2014) Study

The study was a review paper, but there is no indication of the search strategy that was implemented when searching for the articles under review. There is also no indication of the validity of the studies under review. However, the results of the study are consistent across other studies and this makes this study feasible for implementation in our clinical setting. Contraceptive counseling has great potential as a strategy to empower women who do not desire pregnancy to choose a method of birth control that she can use correctly and consistently over time, thereby reducing her individual risk of unintended pregnancy. While the research on which to base specific recommendations is limited, our review highlights the potential value of a shared decision-making approach that focuses on eliciting and responding to patient preferences.

As shown by the results of the study, the population used in the study is similar to our setting and the results can be implemented within our current setting. The researchers were able to consider all clinically vital outcomes and this made the study outcome favorable for our clinic. The treatment recommended in the study would also be beneficial to my patients since they would prefer a method that they understand and can easily recall.

RAPID Critical Appraisal of the Kim et al. (2007) Study

This was a longitudinal study conducted in 2003–2005 at 49 government health facilities in three districts of Nicaragua. The study aimed at testing whether training on and use of the DMT would improve the family planning counseling and decision-making process in Nicaragua. The study results indicate that overall decision-making scores for continuing clients rose far higher among less educated clients (from 18.1 to 29.7, p < 0.05) than more educated clients (from 18.1 to 20.3, p

Implementing the study result within our current setting is feasible because the patients who participated in the study are similar to the ones in our current setting. Allowing our patients an opportunity to select a method that they feel is best suits them is vital in ensuring that they maintain the contraceptive usage and they can recall the knowledge they have learnt regarding the contraceptive.

RAPID Critical Appraisal of the Farrokh?Eslamlou et al. (2014) Study

A systematic review which included all RCTs, including cluster-randomized trials, quasi-randomized trials, and pre-post intervention studies. The researchers conducted a cochrane review of the effects of all intensive counseling techniques including group motivation, structured, peer or multi-component counseling, on contraception adherence. The search strategy used for identifying the applicable studies is well presented and indicated within the paper. The validity of the study has been confirmed and the researchers have indicated the requirements for being included in the study as randomized controlled trials, including cluster-randomized trials, quasi-randomized trials and pre-post intervention studies were the inclusion criteria for the review. The study calculated the effects of interventions using a risk ratio (RR) or the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI), with a fixed-effect model for dichotomous variables. For continuous variables the study will calculate a mean difference (MD) with 95% CI, with a fixed-effect model. For studies with more than 20% loss to follow-up, the authors will use sensitivity analysis based on rates of loss to follow-up. There was a confidence interval of 95%.

The implications of this study to our current setting is that though the patients might be similar to the ones in our current setting, it would not be feasible to implement this tidy in our clinic. The reason is that the recommendations made in the study would not be applicable to our patients since they would prefer a method that is affordable and easy for them to use and recall its usage. If the outcomes for the study were different then it would have been a feasible study for including in our implementation.

The studies that we have used for our literature review have mainly focused on using structured contraceptive counseling. Focusing on the usage structured education has resulted in most of the studies not indicating how effective the particular method used was effective in knowledge retention (De Cetina, Canto, & Luna, 2001). According to our critical appraisal it is clear that there is need to further research on the effectiveness of structured counseling in order to determine the retention rate of the knowledge by the women. What has been apparent is that making by using the different methods for structured counseling healthcare providers can be able to offer comprehensive and similar education to all their patients. Structured counseling will ensure that patients are involved in the decision-making for their preferred contraceptive (George, DeCristofaro, Dumas, & Murphy, 2015). The current clinical setting will benefit from using structured counseling since there will be better information flow and the providers will be using the same information to educate the women.

Section Three: Conceptual Foundation or Model

The selected conceptual model is the Interpersonal Relations Theory developed by Hildegard Peplau in 1952. This model the best for implementing our EBP because it allows the nurse to have an interaction with the patient (Fernandes & Naidu, 2017), which is aimed at improving the knowledge and communication between the nurse and patient. By having an interpersonal relationship, the patient is likely to be more open about their needs for contraceptive and they will be comfortable to ask questions (Deane & Fain, 2016). The interaction between patient and nurse will also foster respect for each other, which will allow them both to learn and grow. Without interaction between nurses and patients, it would be hard for care to be offered since the nurse would only be conducting tests and administering medication as prescribed. However, with interaction the nurse can be more involved in the care for the patient and they can have an interpersonal relationship (Trussell et al., 2013). Communication is at the center of this theory and in the case of structured contraceptive counseling communication should not be one sided (D\\\\\\\'antonio, Beeber, Sills, & Naegle, 2014). There is need to ensure that the nurse and client are able to interact and develop a solution that would be suitable for the client. Contraceptive education is mostly viewed as provider deciding for the client and this makes it hard for the client to ask or question what they are advised to do (Davidson et al., 2015). When using the interpersonal relationships theory, there are changes that would allow the client to interact with the provider, which would change their view and allow them to be part of the decision-making. Knowledge retention would also be improved since the client is part of the process and decision. The purpose of the theory is to assist other to identify their felt difficulties and nurses should be able to apply principles of human relations to the problems that arise.

There are four phases to the therapeutic nurse-patient relationship. This form the construct for the conceptual model. The first phase is the orientation phase that is directed by the nurse and this phase will involve the nurse engaging with the client in treatment, the nurse offering explanations and information, and also answering questions asked by the client (Hochberger & Lingham, 2017). This is a vital phase because it establishes the nature of their relationship and the needs for the client (Sanogo et al., 2003). The second phase will begin when the client now starts to work interdependently with the nurse, feels stronger, and expresses feelings. The third phase referred to as the exploitation phase is where the client will make full use of the services being offered (McCann & Higgins, 2015). The relationship ends when the client no longer needs professional service and this is the fourth phase called the resolution phase. These phases are applicable to our chosen EBP because they align well with the requirements for structured contraceptive counseling. In the first stages it is vital for the nurse to establish the needs for the client by asking questions and interacting with the client. Once the needs have been established, identification of the best course of action or contraceptive method is carried out. This will be the second phase. The nurse is required to offer comprehensive information regarding all the available methods and the client will determine the preferred method. When the client has all the necessary information they will then decide on what method they prefer and ask questions before they settle for the selected method. Finally, the client will have a contraceptive method they are comfortable with and they will not need further counseling.