Abstract
Purpose:
This research examined differences in receipt of recommended preventive services by contraceptive use in adolescent and young adult (AYA) women.
Methods:
Data are from a retrospective chart review of 408 AYA women who received sexual health risk reduction counseling in an urban academic AYA clinic. Descriptive, bivariate, and logistic regression analyses were used to examine relationships between contraception use and receipt of care.
Results:
AYA women aged 12 to 24 years using hormonal contraception were more likely to receive recommended preventive care, including an annual preventive visit and sexually transmitted infection (STI) screening, compared to those using condoms or no contraception. Women using medium-acting reversible contraception (MARC) were more likely to have an annual visit compared to those not using hormonal contraception. Conclusions: AYA women using contraception are more likely to receive recommended preventive health services, suggesting reproductive health visits may be used to promote engagement around preventive care.
Keywords: Adolescent women, Young adults, Primary care, Reproductive health, Contraception use
Adolescent and Young Adult (AYA) preventive care visits are opportune times to address physical, psychological, and social influences on developing health behaviors. Although the American Academy of Pediatrics recommends annual preventive visits for 11 to 21-year-olds, and the Healthcare Effectiveness Data and Information Set uses annual visits as a quality measure,[1] many adolescents do not have yearly visits, and young adults are even less likely to receive annual care.[2] In one analysis, 30% of adolescents had no preventive visits over a four-year period despite continuous insurance coverage.[3] AYA women are more likely than AYA men to receive preventive care, possibly due to visits for reproductive health care.[2,4,5]
Contraception use, including long-acting reversible contraception (LARC: intrauterine devices and implants), is increasing among AYA women.[6] While this may create opportunities to engage women in care, LARC users may require less frequent healthcare interactions, reducing opportunities for preventive care. For example, there is concern that women using LARCs are less likely to receive sexually transmitted infection (STI) screening than those using other methods, [7] although a large analysis did not confirm these findings.[8]
The effect of contraception use on receipt of preventive services remains unclear. This work examined differences in receipt of preventive services in AYA women by contraceptive use.
METHODS
A retrospective chart review was performed of AYA women seen in an urban academic AYA primary care clinic between February 2014 and February 2015. Analysis included cisgender female patients who received care in the LARC clinic or sexual health risk reduction counseling by a health educator. Universal use of risk reduction counselors during clinic visits was instituted to facilitate quality and efficacy of patient care, and this database therefore represents a comprehensive listing of patients. Patients who were pregnant, 25 years or older, did not provide information about contraception use, or received primary care elsewhere were excluded from analysis.
Databases were reviewed to gather information collected during an initial encounter, including contraception use and sexual activity. Patients were categorized by their contraception plan at visit end: no contraception, only condoms, or hormonal contraception, including short- (SARC: pill, ring, patch), medium- (MARC: injection), or long-acting (LARC; hormone IUD, implant) methods.
Two reviewers performed a retrospective chart review to evaluate patients’ receipt of preventive services following initial visit, including preventive visit with physical exam and blood pressure measurement, any ambulatory visit, immunizations, and Neisseria gonorrhoeae/Chlamydia trachomatis (GC/CT) and HIV screening. Analysis was limited to one year given AAP recommendations for annual preventive visits and STI screening every 3–6 months for this high-risk population [1,9]. Annual preventive visits were designated by billing code or reason for visit. Nurse visits for MARC administration, which include screening for acute health issues but focus on medication administration, were excluded from analysis.
Descriptive, bivariate, and logistic regression analyses were used to examine the relationship between contraception use at baseline and clinic engagement measures. Analysis of receipt of STI screening was limited to sexually active women per AAP and USPSTF guidelines [9,10]. All analyses were performed in SPSS Statistics V25. This study was approved by the Johns Hopkins Medicine institutional review board.
RESULTS
During this period, 408 AYA women aged 12 to 24 years were seen in the LARC clinic or received sexual health counseling and met inclusion criteria. Of those, 34% (137) used no contraception, 11% (45) used condoms only, 13% (55) used SARC, 25% (101) used MARC, and 17% (70) used LARC. Most (205, 91%) women using hormonal contraception and half (89, 49%) using no contraception or condoms only reported ever being sexually active. Demographics were similar across groups. (Table 1) In the year following baseline visit, 83% (339) of women presented for an ambulatory visit and 47% (190) had a preventive visit. (Table 1)
Table 1.
Descriptive analysis of demographic characteristics, sexual health risk factors, and receipt of preventive care in AYA women aged 12 to 24 years
| All (N = 408) | Hormonal Contraception (N = 226) | No Contraception or Condoms only (N = 182) | P-valuea | |
|---|---|---|---|---|
| Any Insurance | 397 (97.3%) | 217 (96.0%) | 180 (98.9%) | 0.74 |
| Public Insurance | 337 (82.6%) | 182 (80.5%) | 155 (85.2%) | 0.22 |
| Race: | 0.19 | |||
| African American | 386 (94.6%) | 215 (95.1%) | 171 (94.0%) | |
| Caucasian | 14 (3.4%) | 9 (4.0%) | 5 (2.7%) | |
| Other | 8 (2.0%) | 2 (0.9%) | 6 (3.3%) | |
| Presentation for: | ||||
| Any Visit | 339 (83.1%) | 203 (89.8%) | 136 (74.7%) | <0.05 |
| Preventive Visit | 190 (46.6%) | 119 (52.7%) | 71 (39.0%) | <0.05 |
| Immunizations | 350 (85.8%) | 198 (87.6%) | 152 (83.5%) | 0.10 |
| Sexually Active | 294 (72.1%) | 205 (90.7%) | 89 (48.9%) | <0.05 |
| Among sexually active AYA women, history of: | ||||
| Prior Pregnancy | 78 (26.5%) | 61 (29.8%) | 17 (19.1%) | 0.57 |
| Prior STI | 135 (45.9%) | 99 (48.3%) | 36 (40.4%) | 0.22 |
| GC/CT Screen | 201 (68.4%) | 149 (72.7%) | 52 (58.4%) | <0.05 |
| HIV Screen | 161 (54.8%) | 118 (57.6%) | 43 (48.3%) | 0.13 |
GC/CT = Neisseria gonorrhoeae/Chlamydia trachomatis; HIV = human immunodeficiency virus; LARC = long-acting reversible contraception; MARC = medium-acting reversible contraception; SARC= short-acting reversible contraception; STI = sexually transmitted infection.
P values reported from chi-square tests.
Compared to AYA women using no contraception or condoms, those using hormonal contraception were more likely to have a preventive visit or any visit. Sexually active women using hormonal contraception were more likely to receive GC/CT screening. Compared to women using no contraception or condoms, MARC users, seen every three months by a nurse for injection, were more likely to have a preventive or ambulatory visit. SARC users were more likely to have an ambulatory visit and be appropriately screened for GC/CT. LARC users were more likely to have an ambulatory visit. (Figure 1).
Figure 1: Odds of receipt of preventive care by contraceptive type.
Data presented as odds ratio (95% confidence interval). All odds ratios reflect comparison to AYA women using no contraception or condoms only. Hormonal methods refers to AYA women using SARC, MARC, or LARC.
GC/CT = Neisseria gonorrhoeae/Chlamydia trachomatis; HIV = human immunodeficiency virus; LARC = long-acting reversible contraception; MARC = medium-acting reversible contraception; SARC: short-acting reversible contraception; STI = sexually transmitted infection.
a These odds ratios are calculated using only data from sexually active AYA women.
DISCUSSION
Although less than 50% of the AYA women in this sample received a preventive care visit during the study interval, those using hormonal contraception, particularly methods requiring frequent clinic interactions, were significantly more likely to receive recommended care. In combination with evidence that gynecologists provide 14% of ambulatory care for adolescents and 40% for young women,[4] our findings suggest that AYA women using contraception may receive appropriate preventive care because they present frequently for reproductive health concerns.
Limitations include the use of retrospective chart review, which precluded assessment of biopsychosocial factors affecting engagement in care. Statistical analysis also did not control for demographic variables given the relatively homogeneous sample. The clinic has enhanced sexual health services, including a LARC clinic, MARC nursing protocol, sexual health educators, and opt-out rapid HIV testing, so findings may not be generalizable. Specifically, nursing review of preventive care measures during MARC visits may have contributed to increased receipt of care for this group. Evaluation of this structure and other interventions, such as electronic medical record alerts, may reveal opportunities to improve provision of preventive care at all clinical interactions. Future work should also evaluate receipt of additional measures of preventive care, including depression and cardiovascular risk screening.
Increased receipt of preventive care amongst AYA women using contraception suggests that reproductive health visits may be opportunities to improve clinic engagement around other important health issues. Access to recommended care is particularly important for this population of youth facing significant health, educational, and vocational disparities as they emerge into young adulthood.[12] Future work is therefore needed to explore innovative ways to engage AYA women in reproductive health and preventive care, particularly for those using methods requiring fewer interactions with the healthcare system.
Acknowledgements:
We are grateful to Dr. Pamela Matson, PhD, for her assistance with data analysis, and the Johns Hopkins Adolescent Medicine clinical staff and faculty for their support of and contributions to this work.
Funding:
This work was supported by the National Institute of Health (5T32HD052459; Trent). K.T. and N.W. received funding from the MD Office on Family Planning Program (PI: Marcell).
Abbreviations:
- AYA
adolescent and young adult
- GC/CT
Neisseria
gonorrhoeae/Chlamydia trachomatis
- HIV
human immunodeficiency virus
- LARC
long-acting reversible contraception
- MARC
medium-acting reversible contraception
- SARC
short-acting reversible contraception
- STI
sexually transmitted infection
Footnotes
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Disclosures: The authors have no conflicts of interest to disclose.
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