Research Paper ARTICLE REVIEW

Locate, read, and write about the research and findings in two articles about your topic. These articles should have been published in the past two years in refereed nursing journals. Your paper should analyze, compare, and contrast the authors’ hypotheses, methods, and findings.

Assignment 3 Grading Criteria
Maximum Points
Incorporated and resubmitted revisions to Part 1 (I HAVE THIS DONE) with Part 2.
5
Selected articles appropriate to the topic identified in Part 1 and as per the criteria defined in the assignment.
3
Ensured the paper summarizes selected authors’ hypotheses, methods, and findings.
10
Ensured the paper follows APA format and is written creatively in the student’s own words.
2
Total:
20

ARTICLE #1

The great majority of teenage and young adult women participating in a national survey reported having heard of most contraceptive methods, but levels of detailed knowledge varied, and analyses revealed disparities both by age and by race or ethnicity.1 For example, while virtually all respondents knew of the pill and nine in 10 knew that pill users can switch brands to alleviate side effects, only one in four were aware that a woman does not have to have a pelvic exam before obtain- ing pills. Hispanic women and teenagers exhibited lower levels of knowledge than whites and women in their 20s, respectively, and foreign-born Hispanics were less knowl- edgeable than their U.S.-born counterparts. Differences between black women and whites were few and were less pronounced than those between Hispanics and whites.
In an effort to improve understanding of well-documented racial, ethnic and age dis- parities in unintended pregnancy rates, inves- tigators explored disparities in contraceptive knowledge and attitudes as reported by the 897 female respondents to the 2009 National Survey of Reproductive and Contraceptive Knowledge. The phone survey asked partici- pants if they had ever heard of 12 contracep- tive methods and probed knowledge about particular methods using about two dozen true-false questions; it also included ques- tions on respondents’ self-perceived contra- ceptive knowledge, attitudes likely to affect contraceptive use and background charac- teristics. Racial, ethnic and age differences were assessed in bivariable and multivariable analyses.
One-quarter of women were 18 or 19 years old, and the rest were in their 20s; nine in 10 had at least a high school education. Sixty percent were white, 20% black and 14% Hispanic; 6% belonged to other racial or eth- nic groups. Ten percent overall, and 35% of Hispanics, were foreign-born. Eighty-five percent were sexually experienced, 79% had been sexually active in the last year and 30% were mothers. The majority had some form of insurance; white women were more likely to
be covered by a private plan, and less likely to be enrolled in a public program, than black and Hispanic respondents.
Nearly all women (98–99%) had heard of the pill and the male condom; 87–95% knew of male sterilization, the IUD, the injectable, the ring, the patch, female barrier methods and emergency contraception. However, only 73% were aware of female sterilization, 67% natural family planning and 52% the implant. The proportions answering specific knowl- edge questions correctly ranged widely. For example, the great majority knew that women can switch pill types if they have side effects (86%), that condoms have an expiration date (95%) and that a condom can be used only once (98%). However, only 22% were aware that IUDs are not likely to cause infertility, and 25% that women do not need to have a pelvic exam before obtaining the pill.
The proportions of respondents who said that they knew a lot or everything about methods and their use ranged from 7% for the IUD to 67% for condoms. Sixty-nine per- cent of women believed that they had all the information they needed to avoid unintended pregnancy, and 61% said that decisions about birth control are mainly a woman’s respon- sibility. The contraceptive features most frequently considered important were effec- tiveness in preventing pregnancy and STDs (88% and 79%, respectively); the ones cited least often were low cost (45%) and being hormone-free (37%).
Analyses controlling for age, educational attainment and sexual activity revealed rela- tively few racial and ethnic differences in con- traceptive knowledge and attitudes. While knowledge was generally similar between black women and white women, the former were less likely than the latter to have heard of male sterilization or the ring, and to say that they knew a lot or everything about the pill (odds ratios, 0.3–0.4). Blacks were more likely than whites to consider them- selves knowledgeable about the injectable and to believe that contraceptive decision making is women’s responsibility (2.2–3.2);
they had elevated odds of answering some method-specific questions correctly, but reduced odds of giving the correct response to others.
Hispanic women were less aware than whites of male sterilization, the IUD, the ring, the patch and natural family planning (0.1–0.5). They were less likely than white women to give correct answers to four ques- tions probing detailed knowledge (0.2–0.4), but were more likely than whites to know that petroleum jelly should not be used with con- doms (2.0). They also had elevated odds of considering birth control decisions a woman’s responsibility (2.1) and saying that it is impor- tant for contraceptives to be hormone-free (2.0). Among Hispanics, foreign-born women were less likely than those born in the United States to know of the IUD, the ring and female barrier methods (0.1–0.2); they were more likely to give incorrect responses to several items examining specific knowledge and con- sidered themselves less knowledgeable about the injectable, pill and condom.
In analyses controlling for race or ethnicity, education and sexual activity, the investiga- tors found quite a few differences in knowl- edge and attitudes between 18–19-year-olds and women in their 20s. Teenagers were less likely than young adults to know of female sterilization, the implant, the IUD or natural family planning (odds ratios, 0.5–0.6), but more likely to have heard of the patch (3.2). They were less likely than the older group to give correct answers to five questions mea- suring specific knowledge (0.4–0.6), but were more likely to know that getting the pill does not require a pelvic exam (2.0). Women aged 18–19 had reduced odds of believing that they knew a lot or everything about the IUD, the pill and the condom (0.2–0.4), and of reporting that they had all the informa- tion they needed to avoid becoming pregnant unintentionally (0.5).
The authors note that their sample was rela- tively small and that the numbers of women in racial or ethnic groups other than white, black or Hispanic were too small for analysis. They also acknowledge that they did not assess differences in knowledge by socioeconomic status, which is associated with contraceptive use and unintended pregnancy. Nevertheless, they write, their findings suggest that “clini- cians should be aware that some patients, particularly Hispanic and teenaged patients, may have low knowledge about contraceptive options, and they should be prepared to pro- vide necessary education.”—D. Hollander

References
Teenagers and Hispanic Women Know Less About Contraception Than Young Adults and Whites. (2014). Perspectives on Sexual & Reproductive Health, 46(3), 177-178. doi:10.1363/46e177182

ARTICLE #2

ital Signs: Trends in Use of Long-Acting Reversible Contraception Among Teens Aged 15–19 Years Seeking Contraceptive Services —
United States, 2005–2013
Lisa Romero, DrPH1, Karen Pazol, PhD1, Lee Warner, PhD1, Lorrie Gavin, PhD2, Susan Moskosky, MS2, Ghenet Besera, MPH1, Ana Carolina Loyola Briceno, MPH2, Tara Jatlaoui, MD1, Wanda Barfield, MD1 (Author affiliations at end of text)
On April 7, 2015, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).
Abstract
Background: Nationally, the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs) and implants, by teens remains low, despite their effectiveness, safety, and ease of use.
Methods: To examine patterns in use of LARC among females aged 15–19 years seeking contraceptive services, CDC and the U.S. Department of Health and Human Services’ Office of Population Affairs analyzed 2005–2013 data from the Title X National Family Planning Program. Title X serves approximately 1 million teens each year and provides family planning and related preventive health services for low-income persons.
Results: Use of LARC among teens* seeking contraceptive services at Title X service sites increased from 0.4% in 2005 to 7.1% in 2013 (p-value for trend <0.001). Of the 616,148 female teens seeking contraceptive services in 2013, 17,349 (2.8%) used IUDs, and 26,347 (4.3%) used implants. Use of LARC was higher among teens aged 18–19 years (7.6%) versus 15–17 years (6.5%) (p<0.001). The percentage of teens aged 15–19 years who used LARC varied widely by state, from 0.7% (Mississippi) to 25.8% (Colorado).
Conclusions: Although use of LARC by teens remains low nationwide, efforts to improve access to LARC among teens seeking contraception at Title X service sites have increased use of these methods.
Implications for public health practice: Health centers that provide quality contraceptive services can facilitate use of LARC among teens seeking contraception. Strategies to address provider barriers to offering LARC include: 1) educating providers that LARC is safe for teens; 2) training providers on LARC insertion and a client-centered counseling approach that includes discussing the most effective contraceptive methods first; and 3) providing contraception at reduced or no cost to the client.
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????Key Points
???• Intrauterine devices (IUDs) and implants, known as Long-Acting Reversible Contraception (LARC), are the most effective types of birth control for teens. With use of LARC, less than 1% of users become pregnant during the first year of use.
• LARCissafeforteens,requiresnoeffortafterinsertion, and can prevent pregnancy for 3 to 10 years.
• Nationally, use of LARC among teens has increased but still remains low (<5%).
• Strategies for removing barriers to LARC include: 1) educating providers that LARC is safe for teens, 2) training providers on LARC insertion and use of a client-centered counseling approach that includes discussing the most effective contraceptive methods first, and 3) providing contraception at reduced or no cost to the client.
• Efforts to address barriers at Title X service sites have increased the percentage of teens selecting LARC as their preferred contraceptive option from 0.4% in 2005 to 7.1% in 2013.
• Additional information is available at http://www.cdc. gov/vitalsigns.
?choice for teens that can be combined with condoms to provide the best protection against pregnancy and sexually transmitted diseases (13,14).
National estimates suggest use of LARC among teens has increased but still remains low (<5%) (15,16). Common bar- riers to LARC use by teens include unfounded concerns about safety, high upfront costs, and lack of awareness about LARC (17,18). For example, in a nationally representative sample of U.S. publicly funded family planning clinics, LARC was discussed with teen clients at fewer than half of these clinics (18). Common challenges reported by clinic directors included cost (60%), staff concerns about IUD use among teens (47%), and lack of training on insertion of implants (47%) and IUDs (38%) (18).
The reported barriers to use of LARC prompted CDC and the U.S. Department of Health and Human Services’ Office of Population Affairs to analyze clinic data from the Title X National Family Planning Program. Since 1970, this program has provided cost-effective and confidential family planning and related preventive health services for low-income women and men; it serves approximately 1 million teens each year (19). The Title X National Family Planning Program encourages
health care providers to offer LARC as an option for teens by increasing awareness of clinical guidelines on LARC for teens, training providers on LARC insertion and client-centered contraceptive counseling, and supporting community educa- tion and outreach. The Title X Program also helps its service sites to reduce financial barriers to LARC (e.g., by building capacity to bill third-party payers).
Methods
To examine use of LARC among female teens aged 15–19 years attending service sites funded under the Title X National Family Planning Program, data from the 2005–2013 Family Planning Annual Report† were analyzed. These years include the period during which modern IUDs and implants were available for use by women of all ages, including teens. The Family Planning Annual Report contains data from all entities that receive Title X grants to support delivery of fam- ily planning and related preventive health services through approximately 4,200 service sites. This report includes data on the number and percentage of female family planning users aged 15–19 years by primary contraceptive method and age.
A family planning user was defined as a person who had at least one family planning encounter at a Title X service site in a calendar year. The primary contraceptive method was defined as the method adopted or continued at exit from the last encounter of that year. If a user reported more than one method, only the most effective method was recorded as the primary method. Female clients were excluded from analyses if they were pregnant or seeking pregnancy; they or their partner were sterile by means other than surgical steriliza- tion; or they reported refraining from sexual intercourse. A small percentage of clients (range = 1.8%–5.3% by year) was excluded because the primary contraceptive method at their last encounter was unknown.
Reversible contraceptive methods were placed in three tiers based on the percentage of users who experience pregnancy dur- ing the first year of typical use: most effective (<1%), moderately effective (6%–12%), and least effective (?18%) (8). The most effective methods included IUDs and implants; moderately effective methods included oral contraceptives, injectables (e.g., Depo-Provera), the contraceptive patch, the vaginal ring, and diaphragms; and least effective methods included condoms, contraceptive sponges, spermicides, fertility awareness-based methods,andothermethods,includingwithdrawal.Trendsover time and by age, region, and type of service site were evaluated using the Cochran-Mantel-Haenszel test statistic.
† Available at http://www.hhs.gov/opa/title-x-family-planning/research-and-data/ fp-annual-reports.
Morbidity and Mortality Weekly Report
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Results
Among approximately 7.5 million female clients aged 15–19 years who sought contraceptive services during 2005–2013 from Title X service sites in the United States, the percentage who adopted or continued use of LARC at their last visit increased from 0.4% (2005) to 7.1% (2013) (p-value for trend <0.001); the number of LARC users increased from 4,112 (2005) to 43,696 (2013). During this time, the percent- age that used moderately effective methods decreased from 76.9% to 73.4%, and the percentage that used least effective methods decreased from 22.7% to 19.5% (Figure 1).
By type of LARC, use of IUDs for teens aged 15–19 years increased from 3,685 (0.4%) to 17,349 (2.8%), and use of implants increased from 427 (0.04%) to 26,347 (4.3%) (Figure 2). Use of IUDs was more prevalent than use of implants during 2005–2011 but was surpassed by implants in 2012 and 2013.
By age, overall use of LARC during 2005–2013 was higher each year among teens aged 18–19 versus 15–17 years (p<0.001 for each year). Use of LARC increased from 0.6% to 7.6% among teens aged 18–19 years, and from 0.3% to 6.5% among teens aged 15–17 years. For both age groups, the increase in use of implants exceeded the increase in use of IUDs (teens 15–17 years: 0.05% to 4.5% for implants, and 0.2% to 2.0% for IUDs; teens 18–19 years: 0.04% to 4.1% for implants, and 0.5% to 3.4% for IUDs).
In 2013, among 616,148 female clients aged 15–19 years seeking contraception at Title X service sites, the use of LARC varied markedly by region (Table). Use was highest in the West (9.5%), followed by the Northeast and Midwest (both 6.4%), and lowest in the South (5.3%) (p<0.001). By state, Colorado had the highest percentage of teen clients using LARC (25.8%), followed by Alaska (19.6%), District of Columbia (17.9%), Iowa (16.6%), Hawaii (14.4%), and Vermont (13.8%); con- versely, the lowest percentage of teen clients using LARC was in West Virginia (2.0%), Indiana (1.5%), and Mississippi (0.7%) (Figure 3). By type of LARC, use of IUDs was highest in Colorado (8.2%), Rhode Island (5.4%), New Hampshire (5.2%), and Washington (5.2%), and use of implants was highest in Colorado (17.6%), Alaska (15.4%), Iowa (13.4%), District of Columbia (12.9%), and Hawaii (12.2%) (Table).
Use of LARC among teens aged 15–19 years seeking con- traception at Title X service sites also varied by type of facil- ity. Service sites that focused primarily on delivering family planning services, as opposed to primary care services, had the highest percentage of teen clients using LARC (7.5%), followed by health departments (6.7%), other types of service sites (5.7%), and Federally Qualified Health Centers§ (5.6%) (p<0.001) (Table). By type of LARC, use of IUDs was high- est at service sites that focused primarily on family planning
FIGURE 1. Percentage of female teens aged 15–19 years using moderately effective and least effective contraceptive methods, compared with long-acting reversible contraception (LARC), among those seeking contraceptive services at Title X service sites — United States, 2005–2013
Morbidity and Mortality Weekly Report
100
80
60
40
20
0
???Moderately effective Least effective
LARC
?????????????????2005 2006 2007
2008 2009 Year
2010 2011
2012 2013
FIGURE 2. Percentage of female teens aged 15–19 years using long- acting reversible contraception (LARC) among those seeking contraceptive services at Title X service sites, by LARC type — United States, 2005–2013
8 7 6 5 4 3 2 1 0
??Implant Intrauterine device
???????????????????????????????2005
2006 2007 2008
2009 2010 Year
2011 2012 2013
services (3.3%), whereas use of implants was equally high (4.3%) at health departments and services sites that focused primarily on family planning services.
Conclusions and Comment
These data show efforts to improve access to LARC among teens seeking contraception at Title X service sites have increased use of these methods more than 15-fold from 0.4% in 2005 to 7.1% in 2013, with a marked increase in use of implants. Concurrently, use of moderately effective and least
§ Federally Qualified Health Centers are “safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless. The main purpose of these centers is to enhance the provision of primary care services in underserved urban and rural communities.
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Percentage Percentage
Morbidity and Mortality Weekly Report
TABLE. Percentage of female Title X clients aged 15–19 years using long-acting reversible contraception (LARC), by age group, type of service site, region, and state — Family Planning Annual Report, United States, 2013
?????Characteristic No.
15–19 yrs
Total IUD Implant
% using LARC 15–17 yrs
Total IUD Implant
6.5 2.0 4.5
6.4 1.8 4.6 6.6 2.2 4.4 4.5 0.7 3.8 4.8 0.8 4.0
5.8 2.4 3.4 6.3 1.3 5.0 4.9 1.1 3.8 8.6 2.9 5.6
3.3 0.1 3.2 18.6 2.9 15.8 4.6 2.3 2.3 1.7 1.5 0.1 7.9 2.9 5.0 24.8 6.3 18.6 6.4 1.7 4.8 3.3 1.0 2.3 14.9 2.7 12.2 1.8 1.3 0.6 3.6 0.7 3.0 13.0 1.1 11.9 1.9 1.5 0.4 6.6 1.8 4.9 1.1 0.6 0.5 17.7 2.2 15.5
2.8 1.5 1.4
2.9 0.1 2.8
3.6 0.2 3.5 9.0 3.3 5.7 7.5 2.1 5.5 7.0 2.1 4.9 3.2 0.9 2.4 9.5 1.4 8.2 0.4 0.3 0.1 4.2 0.7 3.5 2.7 1.0 1.7 6.2 2.0 4.2 2.4 1.2 1.3 10.1 3.7 6.4 1.4 1.0 0.5 5.0 1.2 3.8 8.0 3.8 4.1 7.0 1.8 5.2 4.4 0.9 3.4 5.3 1.2 4.1 10.1 0.9 9.1 10.4 3.3 7.1 2.8 1.0 1.8 10.8 3.3 7.5 6.8 1.5 5.3 1.6 0.9 0.7 6.2 0.7 5.5 8.2 1.8 6.4 2.8 1.6 1.2 13.4 2.3 11.1 7.7 1.9 5.8 10.6 4.2 6.4
18–19 yrs Total IUD
Implant
?Total 616,148 7.1
2.8 4.3
2.5 4.3 3.3 4.3
1.8 3.8
1.9 3.9
3.2 3.2 2.0 4.4 1.6 3.6 4.1 5.4
0.3 3.4 4.1 15.4 3.8 2.0 2.3 0.2 4.1 4.9 8.2 17.6 2.4 4.4 1.8 2.0 5.0 12.9 2.0 0.5 1.2 2.9 2.2 12.2 2.9 0.7 2.9 4.8 0.7 0.9 3.2 13.4 1.8 1.3
0.5 2.1
0.6 3.1
4.6 4.8 3.3 5.0 3.5 5.4 1.2 2.1 2.5 6.3 0.5 0.2 0.9 2.9 1.5 1.5 3.1 4.1 2.1 1.7 5.2 5.4 1.6 0.5 2.2 5.3 4.8 3.7 2.8 4.6 1.2 2.3 1.7 3.5 1.4 8.6 4.5 6.5 1.2 1.9 5.4 6.2 1.8 4.7 1.5 0.8 1.2 4.5 2.6 6.5 2.5 1.0 4.2 9.5 1.7 5.6 5.2 6.1
7.6 3.4 4.1
7.0 3.0 4.0 8.2 4.0 4.2 6.7 3.0 3.8 6.4 2.7 3.8
6.9 3.9 3.1 6.5 2.5 4.0 5.5 2.1 3.5
10.1 4.8 5.3
4.0 0.5 3.5 20.3 5.1 15.1 6.7 4.8 1.8 3.2 3.0 0.3 9.7 4.7 4.9 26.6 9.8 16.8 7.2 3.0 4.2 4.2 2.4 1.9 20.3 6.9 13.4 3.1 2.6 0.5 4.5 1.7 2.8 16.0 3.5 12.5 5.3 4.3 0.9 8.4 3.8 4.7 1.8 0.7 1.1 15.7 4.0 11.7 3.3 2.0 1.3 2.4 0.7 1.7 3.7 0.9 2.9 9.9 5.9 4.0 9.0 4.4 4.6 10.7 4.8 5.9 3.4 1.5 1.9 8.4 3.1 5.3 0.9 0.7 0.3 3.4 1.1 2.2 3.2 1.9 1.2 7.8 3.8 4.0 5.0 2.9 2.0 11.0 6.4 4.6 2.5 2.0 0.5 9.5 3.0 6.5 8.9 5.5 3.4 7.7 3.5 4.2 2.9 1.4 1.6 5.2 2.2 3.0 10.0 1.9 8.1 11.5 5.7 5.8 3.4 1.4 2.0 12.2 6.9 5.4 6.4 1.9 4.5 2.6 1.8 0.8 5.4 1.6 3.8 9.7 3.2 6.5 3.9 3.0 0.9 14.1 5.9 8.3 7.1 1.6 5.5 11.7 5.9 5.8
Type of service site
Health department Family planning FQHC
Other
Region*
Northeast Midwest South West
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut 5,556 6.9 Delaware 1,660 3.9
District of Columbia Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada
New Hampshire New Jersey New Mexico New York
North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas
Utah Vermont Virginia Washington
2,116 17.9 22,027 2.5 18,016 4.1
2,787 14.4
3,539 3.6 13,613 7.7 4,539 1.5 9,402 16.6 3,890 3.1 8,787 2.6 5,708 3.7 3,673 9.5 8,436 8.3 8,905 9.0 15,165 3.3 8,258 8.8 12,089 0.7 9,146 3.8 4,382 3.0 2,887 7.2 2,747 3.8 2,982 10.6 10,519 2.1 5,064 7.4 43,748 8.5 16,584 7.4 1,661 3.5 12,599 5.2 10,438 10.0 9,949 11.0 36,229 3.1 2,706 11.6 10,316 6.5 1,564 2.2 17,370 5.8 18,583 9.1 6,679 3.5 1,532 13.8 11,620 7.3 14,457 11.2
333,203 6.7 277,000 7.5 1,738 5.6 4,207 5.7
115,850 6.4 89,359 6.4 199,619 5.3 211,320 9.5
16,677 3.7 1,207 19.6 5,307 5.8 9,734 2.5
144,157 9.0 9,211 25.8
?See table footnotes on next page.
366 MMWR / April 10, 2015 / Vol. 64 / No. 13
Morbidity and Mortality Weekly Report
TABLE. (Continued) Percentage of female Title X clients aged 15–19 years using long-acting reversible contraception (LARC), by age group, type of service site, region, and state — Family Planning Annual Report, United States, 2013
?????Characteristic
West Virginia Wisconsin Wyoming
No.
9,458 6,635 1,834
15–19 yrs
Total IUD Implant
2.0 1.0 1.0 5.6 2.0 3.6 3.6 0.8 2.8
Total
1.8 4.7 3.0
% using LARC 15–17 yrs
IUD Implant
0.7 1.1 0.9 3.8 0.4 2.6
18–19 yrs Total IUD
Implant
?2.2 1.3 0.9 6.1 2.6 3.5 4.1 1.2 2.9
?Abbreviations: IUD = intrauterine device; FQHC = federally qualified health center.
* Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont. Midwest: Illinois, Iowa, Indiana, Kansas,
Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Texas, Tennessee, Virginia, West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming.
FIGURE 3. Percentage of female teens aged 15–19 years using long-acting reversible contraception (LARC) among those seeking contraceptive services at Title X service sites, by state — United States, 2013
???>1 SD from mean <1 SD from mean
?????Colorado Alaska District of Columbia Iowa Hawaii Vermont Rhode Island Washington Oregon New Hampshire Oklahoma Maine Texas California Massachusetts Minnesota New York Maryland Illinois North Carolina New Mexico Virginia Nebraska Connecticut South Carolina Arizona Tennessee Wisconsin Ohio Georgia Delaware Missouri Nevada Alabama Louisiana Idaho Wyoming North Dakota Utah Michigan Kansas Pennsylvania Montana Kentucky Arkansas Florida South Dakota New Jersey West Virginia Indiana Mississippi
???????Abbreviation: SD = standard deviation.
0 5 10 15 20 25 30 Percentage
MMWR / April 10, 2015 / Vol. 64 / No. 13 367
effective methods among teens seeking contraceptive services declined. Given the estimated 4.4 million sexually experienced female teens in the United States (9), and the high effectiveness, safety and ease of using LARC, continued efforts are needed to increase access and availability of these methods for teens.
CDC, in partnership with the U.S. Department of Health and Human Services’ Office of Population Affairs, recently issued recommendations for providing quality family planning services, based on the Title X program’s guidance for direct service delivery (20). These recommendations outline a client- centered approach for contraceptive counseling, in which a client’s reproductive life plan, social needs, and contraceptive preferences are discussed along with medical information to identify acceptable methods for the client. By recommend- ing that the most effective methods be discussed first, these recommendations promote increased awareness of LARC. In concurrence with statements from the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, these recommendations also emphasize the need to include information on the use of condoms for teens to reduce the risk for sexually transmitted diseases (13,14). Despite the long-term protection provided by LARC, it is important that teens have frequent follow-up to reinforce healthy decision- making, promote problem-solving regarding contraceptive continuation and sexually transmitted disease prevention, and receive other preventive health services (13).
Three other initiatives (21–23) have facilitated use of LARC among reproductive aged women, including teens, by under- scoring the importance of educating providers that LARC is medically safe for teens (12), training providers on LARC insertion and use of a client-centered counseling approach that includes discussing the most effective contraceptive methods first (20), and providing contraception at reduced or no cost to the client. These efforts have increased the percentage of teens and young women selecting LARC as their preferred option for contraception and have been associated with declines in teen pregnancies, births, and abortions (21,22).
The findings of this report suggest that implants, as com- pared with IUDs, accounted for a greater proportion of the increase in use of LARC among teens seeking contraceptive ser- vices at Title X service sites. However, national surveys indicate that more service sites, whether privately or publicly funded, offerIUDsthanimplantson-site(24–26).Tomeettheincreas- ing demand for implants by teens, providers should consider increasing on-site availability and affordability of implants.
This report documents that use of LARC among females aged 15–19 years seeking contraception through Title X was highest at services sites that focused primarily on delivering family planning services. This finding is consistent with a recent study of publicly funded clinics, in which those primarily
focusing on family planning (compared with those focusing on primary care) offered more methods on-site, including IUDs and implants (24). Additionally, a 2011 survey of Federally Qualified Health Centers found that a higher percentage of centers receiving Title X funding (compared with those not receiving funding) offered IUDs and implants on-site (25). Together, these findings suggest the importance of providing quality contraceptive services, regardless of setting, to ensure that the contraceptive needs of teens are met.
The considerable state-specific variation observed in the prevalence of LARC use suggests that state-based policies and programs might also influence teen use of LARC. Over the past two decades, many states have expanded eligibility for Medicaid coverage of family planning services. Currently 25 states grant coverage solely on the basis of income, and in 20 states this expansion includes persons aged <19 years (27). Recent surveys have found that Title X service sites in states with Medicaid family planning expansions (compared with those without such expansions) are more likely to provide LARC on-site, report fewer cost-related difficulties obtaining LARC, have extended weekend and evening hours, have a higher percentage of clients paying for services with Medicaid, and assist clients with Medicaid enrollment (24).
The findings in this report are subject to at least three limi- tations. First, to minimize data collection burden for Title X grantees, only summary information on a limited number of client characteristics is requested for the Family Planning Annual Report. This limits the type of questions than can be addressed. For example, it is currently not possible to examine the use of the primary contraceptive method, including LARC, by factors such as race or ethnicity. Second, the use of existing clinic records might have been subject to error regarding the primary contraceptive method provided to teens; however, such records circumvent many of the biases associated with relying on self-report for sensitive behaviors. Finally, the Title X service sites provide care to those from underserved, primarily low-income communities nationwide, including teens, and might not be generalizable to the population of teens nation- ally. However, given the higher rates of unintended pregnancy among teens and low-income women (28), Title X data offer important information on a population with a high need for increased access to contraceptive services, including LARC.
This report documents increasing use of LARC among teens seeking contraceptive services at Title X service sites during the past decade. Approximately one out of every 14 teen clients seeking contraceptive services chose LARC as their preferred method. The type of data presented in this report can help identify areas where barriers remain and guide interventions to increase access to and awareness of LARC among teens. Removing barriers to LARC by educating providers that LARC
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is medically safe for teens, training providers on LARC inser- tion and a client-centered counseling approach that includes discussing the most effective contraceptive methods first, and providing contraception at reduced or no cost to the client, can increase the array of options available to teens and may contribute to the continuing declines in teen pregnancy in the United States.

REFERENCE FOR ARTICLE #2

Romero, L., Pazol, K., Warner, L., Gavin, L., Moskosky, S., Besera, G., & … Barfield, W. (2015). Vital signs: trends in use of long-acting reversible contraception among teens aged 15-19 years seeking contraceptive services – United States, 2005-2013. MMWR: Morbidity & Mortality Weekly Report, 64(13), 363-369.