2017 Public Health Grand Rounds 04/07

PUBLIC HEALTH GRAND ROUNDS Linking Research to Community Health Improvement Jointly sponsored by the Department of Public Health Sciences & URMC Center for Community Health

- It's just barely afternoon, I think.
Welcome to Public Health Grand Rounds.
I'm Nana Bennett.
I'm the director of the Center for Community Health,
and it's my pleasure to welcome you
to Public Health Grand Rounds.
As you all probably know,
the Center for Community Health
and the Department of Public Health Sciences
jointly sponsor these Grand Rounds,
and it's been really a pleasure for our staff
to work with the department for many years now
on Public Health Grand Rounds.
In addition, we are funded in part
by the Clinical and Transnational Science Institutes,
so we always also want to recognize them
for their deep commitment to population health
and to supporting these Grand Rounds.
So, welcome.
Today it's my pleasure to introduce
Dr. Andy Aligne and his team.
Dr. Aligne is the director of The Hoekelman Center
in the Department of Pediatrics
at the University of Rochester.
The center trains young physicians
to become leaders in community health and advocacy.
In addition, Dr. Aligne is leading
the Greater Rochester LARC Initiative,
which we're going to hear about today.
It's an evidence-based approach
to preventing teen pregnancy;
and as you know, teen pregnancy has been
a huge public-health issue for many years now.
Dr. Aligne's original research on social determinants
of child health has been published
in leading scientific journals.
He has received the Outstanding Faculty Teaching Award
from the pediatrics residence of Rochester,
and he's also, and this is true to my heart,
a recipient of the URMC's Dr. David Satcher
Community Health Improvement Award.
And just a quick plug and reminder,
that next Tuesday, we will be having the Satcher event
and awarding this year's Satcher Awards,
so please, do come.
Dr. Nicole Redmond from NHLBI will be our guest speaker,
and that's at noon on Tuesday.
Joining Dr. Aligne today is Selena Ruiz,
a health educator at Monroe Council for Teen Potential.
She has,
did I do something? (no mic pickup)
Oh, Metro Council, I'm sorry.
She has more than 13 years experience working with youth
in the Rochester City School District.
Also joining Dr. Aligne is Jessica Coleman.
She is a community health educator
with Highland Family Planning.
She educates youth in schools
and community settings to make safer decisions
for their sexual health.
Within the LARC Initiative,
Jessica presents about the referral process
for individuals to gain access
to LARC birth control methods.
Please join me in welcoming Dr. Aligne and his team.
(audience applauding)
- Thank you, Nana.
I'm very happy to be here today,
have this opportunity to talk to you
about the preventing teen pregnancy with LARC project,
better known as the LARC Initiative.
This is a group effort.
It's run out of the Hoekelman Center
and the Department of Pediatrics,
and our project coordinator is Jessica Cranch.
She's sitting in the front row, here,
is also an MPH student here.
And so, if at the end of this,
this sounds really interesting and you can think
of a place that could benefit from a LARC talk,
she'd be the person to connect with about that.
Our core partners from the beginning of the LARC Initiative
are Planned Parenthood, which is where we found
our initial champions for promoting LARC
to prevent teen pregnancy.
MCTP, the Metro Council for Teen Potential,
which is an umbrella organization
of positive youth development agencies
and other kinds of organizations that are doing things
to prevent teen pregnancy,
and Highland Family Planning,
which at the time, was one of the few places offering free,
confidential family planning services for teens.
And we are very grateful to have had the support
of the Greater Rochester Heath Foundation
for this initiative.
I have tell you this,
that my wife is a paid speaker for the maker
of the contraceptive implant, which could bias me
in this presentation.
So, getting right to it: what is LARC?
LARC stands for Long-Acting Reversible Contraception.
The reversible part is important.
And basically, it's two different kinds of contraceptive.
On the one hand, the contraceptive implant,
that's about as big as a matchstick and goes in your arm,
and the IUD or intrauterine device,
which that picture gives you an idea
of about how small it is.
It doesn't go in your fingers, though,
it goes in your uterus.
And we have models of these for people who are interested,
who want to see how small they are,
or touch and feel them, that we can pass around here.
Alright, so why are we even talking about this?
As Nana mentioned, teen pregnancy has been
a public health priority in the US for a long time
because it has a number of potentially serious consequences
for the teen mom, for the infant, for further down the line,
the child of teen moms, and on
into the next generation as well.
And some of these problems
have pretty important risk ratios assorted with them.
And so, if you have serious problems
and big risk ratios, and if the underlying risk factor
is prevalent, you can wind up with a big problem.
So how prevalent is teen pregnancy?
So, this slide from the CDC helps us to see,
comparing US versus other rich countries
and comparing in the US and in these other countries
over time.
So, from 1970 to 2013, looking at the first two columns
on the left, what you see is the teen pregnancy
has gone down a lot in the US,
which is a good thing.
But our baseline was so much higher to begin with
and the other countries have been declining even faster
than we have, despite starting at a lower baseline,
that we're still way behind these other counties.
So, for this slide, in 2013, which is the year
before we started the LARC Initiative,
the US had a teen pregnancy rate
of between 25 and 30 per 1,000.
And zooming in on Rochester,
what you have here is a map of the zip codes of Rochester,
and you see on the legend that the darker red you have,
the higher the teen pregnancy rate is.
And we, again, at the time of starting the LARC Initiative,
had zip codes in Rochester where teen pregnancy rate
was greater than 100.
So, remember, going back to the previous slide,
other rich countries have single digits,
and Rochester's got some places that are up over 100.
So, this is something to do something about,
but we know because of all these rates declining,
that it's possible for these rates to decline.
And so, the CDC has highlighted teen pregnancy
as a winnable battle.
I mean, this is something that we should focus on
because it's something we can do something about.
We have the tools to fix this problem.
And one of the tools that they specifically recommend
is promoting LARC.
And this slide is a little busy.
It's the health impact pyramid from the CDC.
And the point in this is to illustrate
that these issues are multiple factorial,
and so you need multi-component interventions
to do something about them.
The things that are gonna have the biggest impact
are the things that are at the bottom of the pyramid.
So, addressing education and poverty.
So, yeah, that is wonderful if you can do that.
That's gonna have a huge impact
and a huge bang for the buck.
But those are also things that are very hard to do.
At the top of the pyramid are things
like clinical interventions and individual education,
and those things don't have as much of an impact.
But you need all of these in synergy
to have a public health impact.
And so, largest, there in the middle,
and you can look at this,
and you can say, well, this is really discouraging.
'Cause if you need to do all of this stuff
to have an impact, then any one thing by itself
isn't gonna fix the problem,
then why bother doing any of the things?
But you can also flip that vicious cycle mentality around
and say, well, okay, we're not gonna do everything
all at once, but if we can start with something
that's evidence-based, that's affective,
that's really gonna work, then we can get
a positive feedback loop going.
Because if you can decrease teen pregnancies with LARC,
then you can decrease school dropout,
you can decrease poverty in teens and in their children.
And then you can get that benefit of addressing SCS
that which, in turn, will decrease teen pregnancies.
And one of the handouts that we have outside
from MCTP is giving you some of the up-to-date statistics
on teen pregnancy and talking about that connection.
Because, you know, we're talking all the time
in Rochester about school performance.
We're talking all the time about what to do about poverty.
And maybe, effective interventions
for teen pregnancy prevention
could be part of that discussion.
And everybody involved in this area
is agreeing that LARC is an important part of this.
So the American Academy of Pediatrics,
the American College of Obstetrics and Gynecology,
the CDC, are all in agreement that LARC
should be first-line contraception
for sexually-active teens.
Alright, and why are they so excited about LARC?
Why do they say that?
So this is a chart from an organization
called Bedsider that you can get online for free,
if you want.
It's one of the things that we show in the LARC talks,
and that we give as a handout.
And this is a very clever thing,
because what it's done is it's organized
the different kinds of contraception
by how effective they are, as opposed
to the way I learned about it,
which is what kind of chemicals they use
and stuff like that.
So, this is saying here are some things at the top,
in the orange line that work really, really well.
And you can see, it's basically all LARC
except for sterilization.
But sterilization is permanent,
whereas all the LARC methods are reversible.
If you don't want the LARC in anymore,
you can get it taken out and you can get pregnant.
But while it's in, it's gonna last.
You know, long-acting is really long-acting.
Long-acting means years.
So, some LARCs can last 10 years or more.
And that has an advantage, over methods in the middle row,
like the pill, which is the first thing
that lots of people think of,
because the pill, you've got to take every day.
So behaviorally, that's just gonna be a barrier
to effective use in the real world.
And you can see that going from the top row
to the middle row, you immediately get a big jump
in how many people are gonna get pregnant per year
using those kinds of methods,
going from less than one in 100 women,
to six to nine in 100.
Alright, and in the bottom row,
we have things that really work not that well.
12 to 24% of women getting pregnant in an year,
using those methods.
So things like withdrawal, and also condoms.
So the thing about condoms is we still want people
to use condoms, if they're sexually active,
for STD prevention.
And so, we always talk about dual use,
and we recommend that.
But if you're relying on a condom alone
for pregnancy prevention, you should be aware
that it's not that effective.
Alright, so what this slide is showing
is what's been happening in the real world,
or what people are actually using.
And it's backwards from what is being recommended,
and what the Bedsider chart would indicate
is the way that things ought to be.
So, if you look at what teens are using a lot,
it's the things that are blue,
which is the things that work not so well.
If you look at the things that they kinda use,
it's the things that are only kind of okay.
And if you look at the things that work really, really well,
that's what they're using hardly at all.
So, what can we do about that?
Well, one of the things is this study,
the CHOICE study that was done at Washington University
in St. Louis, which asked this question.
And their hypothesis was that people needed
to have correct information and easy access
to these methods.
And they did that.
So they gave people the kind of information
that's in the Bedsider chart.
And they made sure that all these methods were available
at no cost.
And what happened?
What happened is that over a while,
mainly women, including teens, chose LARC methods
as the most popular kind of method.
And when they did that, they kept them in use longer.
They enjoyed using them.
They were happier with those methods
than people who chose other methods,
and they worked better at decreasing pregnancies.
And so, our intervention with the LARC talks
has been to help to get that information out.
And we use an academic detailing model.
And this is based on a CARE project,
which are the projects that residents can do
as volunteers in the pediatrics and med-peds departments.
And so two residents, Dr. Hilary Yehling
and Dr. Anne Huber noticed in their practice
that teen pregnancy was a problem in Rochester
and they wanted to do something about it.
And they started this little project
called Evidence-Based Contraception
using a slide show developed by Dr. Rachel Phelps
where they went out to different doctors' offices
in town and told them about these newer methods.
And it really didn't have much of an impact.
So we went back to the drawing board,
'cause we learned something from it,
and we still thought this was a good idea.
And we designed a new kind of intervention
that became the LARC Initiative, and got support
from the Greater Rochester Health Foundation.
And so the things that we changed were
that instead of having residents go out,
we had attending doctors go out,
and we also had health educators at each visit.
And instead of just going to doctors' offices,
we also went to community based agencies.
And about half of our talks have been
for non-medical audiences in the community.
We increased the quality of the lunches that we gave people
from the cheapest pizza we could find
to some nicer salads and sandwiches.
And ...
We ...
Still stayed otherwise with the general model
of what we were doing, which is talking to adults.
So that's something that kind of seems strange
to people up front about how are you doing
a teen pregnancy prevention initiative
if you're not talking to teens.
But we're talking to adults who work with teens,
with the idea being that when teens have questions,
the people that they trust,
the people that they're going to talk to
are going to be able to give them accurate information
about the safety and effectiveness of LARC.
And that's something that we haven't changed
since the beginning.
And then the other thing that we really have stressed
in the LARC Initiative versus the resident project
is talking about places that you can refer teens for LARC
if you don't want to be doing it in your practice,
or if you're a non-medical organization that's not doing it.
Alright, and so, this is just a picture
of the two residents, Anne and Hilary
who start the evidence-based contraception project.
And Allison Marsh, in the middle,
who was an MPH student here, and who helped us
to write the grant for the LARC Initiative.
So, what have we done so far in terms of the processes
of the LARC Initiative?
We have presented to over 1,000 people,
so about 500 doctors, nurse practitioners, nurses,
people in medical settings,
and about 500 people in community settings,
so teachers, people who work in after school programs,
people who work in youth development, all kinds of people.
We have, in addition to that, facilitated LARC training
for doctors who want to be doing LARC insertions themselves
but weren't trained in that and needed to get trained in it.
We've also facilitated getting enrolled
in the Family Planning Benefits Program
with presumptive eligibility because that's something
that is, it's a lot of mumbo-jumbo, it sounds like,
but it's this wonderful program that we have
in New York State that not all states have,
where it's free and confidential.
It started in clinics for teens
to get reproductive health services.
And so we've actually helped clinics to become part of that
if they wanted to.
And then we've done general awareness raising,
like with Grand Rounds to let people know about LARC,
and the LARC Initiative.
And so going back to that CDC pyramid,
and the kinds of things that they recommend to do,
we have tried to be doing the different components
of your broad public health interventions.
So mobilizing the target community,
we've been getting out, getting the word out.
Educating key stakeholders, we've been doing that.
Implementing evidence-based teen pregnancy prevention,
so LARC is definitely evidence-based.
Increasing youth access, we've been doing a number of things
to increase youth access to LARC.
And assuring reproductive health needs
with diverse youth, we've been focusing
on the urban parts of Rochester,
'cause that's where the highest teen pregnancy rates are.
And we've also been going all around
the county of Monroe, too, and sometimes,
a little bit beyond that.
And so, here are our results, so far.
These are data from our initial clinical partner sites.
So, Highland Family Planning, Planned Parenthood,
the Women's Health Practice of Strong, and AC-6,
which is the peds practice of Strong.
Did I forget anybody?
Okay, great.
And so, what you can see here is that at the beginning
on the left of the graph, things were going up
a little bit anyway, but we're pretty flat.
And around the time that our interventions starts,
there's a big up-tick in LARCs inserted
(audio skips) at these clinical sites.
And throughout the initiative, we've managed to stay
above what our actual target was.
So, we feel like this is good evidence
that we are having impact with the LARC Initiative
of getting the word out and increasing
what's supposed to be happening
according to the CDC, et cetera.
Alright, and then this is another indicator
that we're having success.
These are government statistics from something
called the YRBS, the Youth Risk Behavior Survey.
And what this number is looking at is LARC use
in sexually-active female high school students in 2015,
so about a year after we started the LARC Initiative.
And you can see that in RCSD, the number's around 16%,
as opposed to 7% for all of Monroe county,
5% for all of New York State, and 4% for the nation
as a whole.
So, if you look all around the country,
the City of Rochester has one of the highest rates
of LARC usage at this point.
And we're waiting to see what the next round
of YRBS is gonna show.
And then this is an interesting thing that happens
when you do community health work,
is that sometimes, you have ripple effects.
And one of the ripple effects that we've had
from the LARC Initiative is a satellite project
of a resident Dr. Emily M. Sadoski
who heard about the LARC Initiative and was convinced
that, yeah, pediatricians should be doing it.
And then said, well,
but if pediatricians should be doing it,
then residents should be getting trained
how to do it during residency,
and with some help from us,
went out and got trained herself,
in how to do LARC insertions,
and then decided to figure out how to offer that
to some of the other residents.
So she did that.
And then, took it to the next level,
and with the help of other people in the residency program
in the peds department, did a system change
where now all of the residents in pediatrics here
are getting trained in contraceptive implant insertion.
As far as we know, it's the only pediatrics department
in the country where that's true.
And so that has had a ripple effect, too,
which is that by offering all of these training sessions
for the residents, all kinds of doctors
who aren't residents anymore,
who are out of residency but never got trained
'cause the training didn't used to be offered at all,
came to these sessions and got trained.
And so then, we got all kinds of docs
in private practice starting to do Nexplanon,
and other people in other locations starting to do,
I shouldn't have said the brand name, sorry,
starting to do a contraceptive implant insertion
in places that weren't doing it at all
or thinking about it when we started the LARC Initiative.
Alright, so what are our next steps?
We have a paper on the attitudes that teens had
about different kinds of contraception.
It's been accepted for publication.
And the person who did a lot of the initial work
on that at the beginning is Nina Piazza,
who is a medical student finishing up this year.
And we have a paper about Emily M. Sadoski's
project that's under review.
We're working with Causewave on a campaign
called The Collective Impact campaign.
Causewave is the agency,
used to be known as the Ad Council.
You've seen their PSA kinds of announcements
for all kinds of stuff around town.
And we're thinking about how do we evaluate
the overall impact of what we've been doing
in the LARC Initiative,
'cause it looks like we're having some success,
but this wasn't set up from the beginning
as a research project.
It's not a randomized trial,
but we think we have some decent evidence
of effectiveness.
And then, beyond that, what are we thinking about doing?
So this is a picture with snow,
of the Rochester area.
It's still snowing.
And so, one of the things is that there has been,
nationally, a focus on doing something
about teen pregnancy prevention in urban areas,
'cause that's where teen pregnancy rates were the highest,
and there's been a big decline there,
but there hasn't been a similar decline
in rural areas where there's also high teen pregnancy
and high poverty.
And so that's an area for potential expansion.
There are also still lots of places
that it might be good for us talk to
that we we haven't been to, yet.
Then, at a bigger picture level, is this a good model
for community level teen pregnancy prevention
that we could help to share with other places:
Buffalo, Syracuse, and beyond that?
And at an even bigger picture level,
is this a good model for generally expanding
the use of effective teen pregnancy prevention methods,
not teen, other kinds of prevention methods?
So, like prevent type II diabetes or whatever.
Would this be giving academic detailing
with medical experts and health educators or whatnot?
Would this method be good for doing that?
So, we have lots of people to thank.
This is only some of the people who've had a role
in the LARC Initiative, and some of the organizations.
And so, I won't read all that,
but thanks to everybody, whether you're on the list or not,
for helping out.
And again, if you're interested
or know of a place that you think would be good
for having a LARC talk, then think about that,
contacting us.
And if you want to try to reach us,
you can reach us here.
And happy to take any questions in a minute,
but first I want to hand things over
to our partners.
And first, Selena.
- Hello, good afternoon.
Thank you for the opportunity to be here.
So to give you a little bit more background information,
I work on a grant called THRIVE.
I work for Metro Council for Teen Potential.
I am a health educator as well on the THRIVE grant.
So, my job is pretty much,
I facilitate curriculum with youth in different settings
about sexual health and pregnancy prevention.
So, I get to actually talk to kids
about LARC methods and hear their reactions
and answer their questions and kind of hear
what some of their concerns are,
or the myths that they think are are true
and those kinds of things.
So, I kind of get that boots on the ground experience.
So that's why I get to be here today
and answer some questions for you all as well.
But I do, I love the work that I do.
I think I really believe in LARC.
I believe in the LARC Initiative.
I know that kids, a lot of times,
they were completely unaware of these methods.
And once they are aware of these methods,
they're like, oh, wow, you know I never considered
that it would be that easy or that I could not worry
about pregnancy for 12 years or for five years.
I don't have to worry about it for three years,
or things of that nature.
So, I think that oftentimes,
it's easy to kind of look at kids
and use one paintbrush to paint them all.
And it's important to consider
that as we educate kids, our job
is just to give them all the information we can
so they can make the choices they make, you know?
So I think that's why I love my job
and I look forward to expanding this the most that we can.
So, yeah, I guess that's my piece.
- Okay, so, hi, my name's Jess Coleman.
I also am under the THRIVE grant as a health educator.
And I'm one of the health educators
who presents for the LARC Initiative,
so I kind of couldn't see from both of those perspectives.
I definitely do get to hear the first hand
what young people think about these methods.
A lot of times, we health educators
are combating what they heard from granny and from mom,
because there is a history
of reproductive disenfranchisement,
especially for groups of color.
And so, some of the youth that we work with,
their mothers grew up, and their grandmothers grew up
in a time where those IUDs did not look
quite how they look today.
They were scary.
If you've ever seen a Dalkon shield,
very scary looking.
And so, we have kind of dispel
what people have grown up understanding
and believing about those things.
So we're doing that hands-on,
but then on the other side,
with the LARC Initiative, we're going in
and talking to medical professionals,
anyone who works with youth, really.
Because we can do those things in the classroom.
We can talk about the reality in the classroom.
And those will have those impacts.
You know, we're there, we do like an eight time session
with the groups that we work with, for some of the groups.
And we're there for those eight sessions,
we can answer those questions,
and then they go back home and are still hearing
the same messaging.
Or they go to their doctor's office,
or they go to the community center.
They're stilling hearing those same messaging,
and we're not there long-term.
So, that's why it's so important to really
be talking to the adults that work with youth
and be able to kind of full circle dispel the myths
and make sure the reality of these methods are getting out.
We also have to walk that fine line
of not being coercive and making sure
that this really is a matter of youth
making decisions for themselves.
We know how great these methods are,
and that still doesn't mean that they're right
for everybody, but we wanna make sure
that we're giving factual information,
and that they're not basing those decisions
on those scary IUDs of the past.
So, the health educator's role is one,
having that hands-on perspective
to say, youth, think this is what youth are saying,
and then also to talk about the referral process
for getting someone really on any of these methods.
So, the clinics that are involved
with the LARC Initiative all do accept
the Family Planning Benefits Program,
and so we talk to these people who work with youth,
the doctors, community members, whatever it is.
We talk to them about what that referral process looks like.
And they can come to us for a number of reasons.
So, if they have no insurance at all,
a person can come to an FPBP site.
If they are under insured
and are worried about the coverage,
again, they can come to these sites.
Or, if they have a doctor or medical provider
who doesn't specialize in LARC methods.
So, examples of that might be pediatrics,
or if someone's on a college campus
and the health center at the campus
doesn't provide these methods.
That's a really easy referral to us.
Send them over and then they come right back to you.
So it's not a matter of taking people's patients,
it's a matter of people getting what they need
for their sexual health.
I was taking notes.
Let me try to cover all I want to.
And I just think also, just looking at the slides
that Dr. Aligne provided.
It's interesting to look at that we are,
Rochester is so much higher in a lot of the birth rates,
teen pregnancy rates, are a lot higher than New York State,
Monroe county as a whole.
So Rochester is typically higher than Monroe county,
New York State and the US as a whole,
but then you see the comparison, the difference
between the LARC methods, that that's really awesome,
and I think it's really reflective
of this initiative and the work that we're doing.
And so, we hope that it just grows
and gets bigger than that.
So, thank you.
(audience applauding)
- Yeah, I (no mic pickup)
Can people hear me?
Alright, so (no mic pickup)
Right, so, the common thing
that both Jess and Selena brought up
and that I do think is the most important part
of this is that, is that we're giving people information,
scientifically, medically-accurate information
so people can make informed choices.
Are there any questions?
(no mic pickup)
So the question is,
what do teenagers think about methods.
- Is that actually working?
Can you guys-- - Yeah.
- Okay, it is? - Alright, fine.
A lot of kids will always listen to each other,
almost more than they listen to adults.
A lot of times, peer influence is really strong,
so that's why I think what we do is really important
in how we relate to the kids,
but like I said, a lot of times,
kids are unaware of LARC.
They think the Depo, or they think that the pill
are really their only options, or condoms.
So they might might know about an IUD thing,
but they think, oh, well, that's only
if you already had a baby, so that's not an option for me.
I've heard things like that before.
Or getting an implant is really, really painful,
so I don't wanna do that.
So, just little education around that,
like small things that we challenge them in some ways.
Like I'll say, during our classes
when we talk about these things,
I'll say things like, well, getting an implant
in your arm might be painful, a little bit,
but having a baby is very, very painful for a while.
You know? (audience chuckling)
So, that's a little bit of a challenge.
Then they kind of laugh the same way that you did.
And they're like, you know, that's a pretty good point.
And that will take care of that.
I will avoid a pregnancy for three years.
And that's a little bit more secure than a pill
that you have to take every day.
So, we have these conversations.
Just opening these conversations,
the kids are more than willing to talk and ask questions.
So that that shows me that they have a hunger
and a desire to learn.
So I think if anything, that shows a reflection
of their attitude towards these things.
They want to know, and there's a willingness to learn.
So, now you?
- Yeah, I think that was a really great answer.
And just a couple other,
you know, those things will mess you up.
Or, it's a conspiracy, like they don't want--
- Gain weight. - Right.
Yeah, so just like those kind of typical,
and some of them are just reflective
of birth control as a whole, these sweeping statements
about hormones and all that stuff.
But I think they way that you talked about addressing it,
I think is really good.
Definitely talking about the alternative is a pregnancy.
You have to think in those terms,
the likelihood of a person becoming pregnant
is obviously much higher if they're not using
any birth control method.
(no mic pickup)
- [Andy] The people that we're talking to work
with everybody.
And then I'll pass it.
(audience chuckles)
- We talk to all, to everyone, especially be like,
I know in one of the schools that we worked in,
a young man came up to us after one of the classes
and said, "My mother had me when she was 15,
"and I wouldn't want that for anybody.
"I wouldn't wish that on anyone."
And it kind of struck my coworker and I,
because we weren't sure if he was talking
about his experience as the child or his mother's experience
at having a kid at 15.
Maybe both.
And so we don't want to assume that this
is just a female bodied person issue
who is capable of pregnancy.
This affects everyone really involved.
So, we definitely talk to everyone, so.
- Yeah, and any of our health education
we really try to make relevant.
So, right.
You know, we've done birth control demonstrations
to groups of all guys.
And really start out from the beginning,
like why would this be relevant to you, right?
If anyone's having the type of sex
that could lead to a pregnancy, this stuff is relevant.
The other thing, too, is for trans folks, for example.
LARC methods might be a really great option
for someone who might be trying to avoid a period.
That could be reflective of a gender
that they don't identify with,
or for someone who might, again,
might be having the type of sex that could lead
to a pregnancy, they they are really just not interested in.
So also try to be mindful of who our audience is,
and making sure that we're making the information relevant
and accessible to a wide variety is definitely important.
- One more thing, I'm sorry.
And one more thing.
Like I said before, they listen to their peers
more than anything, so we want to educate all of them
and encourage them to educate their peers, too.
So that's another reason.
Another question?
- [Audience] My question kind of relates
to what you were talking about as far as things,
how (no mic pickup).
- So the question was,
as we talk about how they listen to their peers,
she asked how are we harnessing that,
or kind of using that to our advantage in this initiative.
So, the grants that are currently at work here
in Rochester, we have the THRIVE grant
and then the CAP grant, which are two grants
that work together to work on at this issue.
Both of these grants have a teen leadership component,
where we work with ongoing groups
and we pick teen leaders who then help plan events.
We did an event in February around Valentine's Day,
that had a testing component,
where kids were able to come and get tested,
and they knew at that event.
Trillium was there.
Highland Family Planning was there.
So they are exposed to these things.
And those youth that are in the leadership groups,
they sit at meetings.
They learn about the curriculum that we use.
They have a lot of contact with us, the educators,
so that they can be, also, educators in their peer groups.
So, and then also, on a smaller scale,
just in every class that we teach,
we always say, even if, 'cause again,
we leave it up to them for their choice,
so I say, abstinence is absolutely your choice, too.
And some of you may be sitting in this class
and saying I'm not active, so this isn't important to me.
Well, it may not be important to you personally
for your use, but it may be important
to someone you know.
So you can use this information
and be an expert to someone you know.
So we encourage them, even on that small scale
to be leaders in that sense as well.
So, does that answer your question?
- Yep. - And those youth leadership
groups also get LARC talks on top of that.
- [Audience] I had two questions about accessibility.
One is that I've heard that insurance reimbursement
to physicians for LARC is (no mic pickup).
And that that's been there for practices that are not part
of (no mic pickup).
So that's one question,
and the second question is,
in addition when my kids were in Rochester,
Planned Parenthood was (no mic pickup).
- [Andy] So the question was
about insurance reimbursement and then about access
in general to physical locations for services.
And so those are things that people are aware of
and working on in different ways.
We had a conversation right before this
about one of the really big issues
has been post-partum LARC
that people in the field have sort of felt
like this is an obvious thing to do.
The doctors want to do it.
The women want it.
And that, specifically, was something
that you could not get reimbursed for.
But that's changed, and I just got an update
that it's being implemented effectively.
So that's a change in a positive direction.
Depending how far back you want to go,
contraceptives and other preventive things
were not covered under insurance,
which is why the Family Planning Benefits Program
was so important.
They should be covered under insurance now,
so anybody should get reimbursed who's doing them.
The practical issues are for pediatricians,
that it's sort of the same thing as with vaccines,
is that you buy a supply ahead of time,
and you don't get reimbursed until you use it.
And so before you've started doing that,
you don't know if you're ever going to use it.
You're maybe not super excited about another thing
that you have to buy that you may not get reimbursed for.
And so that's something that's happening
one practice at a time, as early adopters get into it
and see that they can make it work.
And then other people learn from their experiences
about how that worked.
The reason that we talk
about Family Planning Benefits Program
within our LARC talk still, a lot, even though
things should be covered other places
is that one thing that's important for teens
is often confidentiality.
So for lots of teens, maybe half of the teens
who come to the different teen clinics in town
or pediatric practices, they're coming in with their parents
to talk about contraception and everybody's okay with that.
And that's the ideal situation.
But for the other half of teens,
maybe I'm sort of guesstimating,
they are not gonna come in for these services at all
if they can't get them confidentially.
And the way that lots of things,
it just turns out practically.
This is how it's set up.
It doesn't necessarily have to be,
but the explanation of benefits,
which is the bill, goes home to the parents.
So even if the teen has signed up with the doctor,
and the mom has signed off and dad
has signed off that they can go to the doctor
and have it all be confidential,
the bill with why they came and what services they got
goes home to the parents.
And so, then it's not confidential.
So the fact that we have places where teens can go
and get free, confidential services
is still really important for lots of teens.
And then the question about doing things to increase
just the physical accessibility of different clinics.
There are programs in town
that involve providing transportation
and taking people to the different clinics
to see where they are and how they are,
and stuff like that.
And people are working on that,
on increasing the ability for teens to come in
and not only get things free and confidentially,
but ideally, even same day.
- Yeah, some examples: bus passes,
offering bus passes at the clinics.
There are also, are schools with health centers
right in the high schools that will provide,
I believe, just the implants.
I don't know that, I don't think that, IUDs,
but still having that access right there,
so a person doesn't have to travel and get somewhere.
But definitely, like the bus passes help with travel,
within the city, especially.
- And I know we, as we educate,
we tell them where these clinics are.
We try to constantly let them know
that this where these services are.
We invite Highland Family Planning
to come in and talk about birth control,
and where their clinics are,
and how the insurance works, as well.
So, again, that education piece I think is major.
If kids know what's available, they'll go.
Any other questions?
(no mic pickup)
- [Andy] Right, so the data
from the rigorous studies on this
is that continuation rates with LARC methods
in women including in teens
are actually much higher than with other methods.
I think that some of what happens
when you hear things from people locally
is that there's a servant ascertainment bias
that you see the people who come back in
to get their LARC removed, but you don't see the people
who don't come in, by definition,
'cause they don't come into get it removed.
And so that creates this impression
that there are lots of people getting them removed.
Now, having said that,
if somebody wants it removed,
it's really, really important that that's their right.
And that's a service that's part of being able
to offer LARC, is to also remove LARC.
It's reversible.
If people want it out, they can get it out.
- Yeah, to expand just a little bit.
So, you know, a lot of times, in classes,
we talk about you're a lot more likely
to hear the horror stories, I guess you could say,
than you are to hear about the people
who are walking around happily, who are not coming back
to the clinic.
The other thing that you're not seeing
at the clinic is the people who stop taking their pill,
the people who don't come back for their shot,
you know, like all those things.
It happens, but that's not,
it doesn't take another clinic visit
for that to happen, so it's not as, I guess, monitored.
(no mic pickup)
- [Dr Aligne] Yeah, so the question
is about differences in barriers between urban,
suburban, versus rural areas.
Is that it? (no mic pickup)
And the answer is we personally don't really know yet
for the Finger Lakes/Rochester area
except that the issues are different
from everybody we've started talking to.
So transportation, which somebody brought up,
is a much bigger issue, and on from there.
And there's not much to look at
in terms of national studies, either,
which is part of the issue.
- I think even some of the programs
like what we do in rural areas
are a little bit less likely to be,
I think, some of the,
some barriers can be just the way that schools are run.
Like, our district is very helpful
in letting us come in and teach.
You know, different districts have different,
I guess, ideas on what, how they want sexual health taught.
So those could be barriers, depending on the district
and kind of just the attitudes around sexuality
in different places.
So, that could be.
- [Andy] And then, you know, the other really big thing
is the facilitators in the different,
which I think you also included in your question.
So, when we started the LARC Initiative here
in Rochester, there was a lot of stuff
that we didn't have to reinvent from scratch.
And that's a big thing that we try
to do in general in the Hoekelman Center,
is try to partner where we can
and not do the work of other people,
that they're already doing.
And so had organizations like MCTP
and all of their member organizations.
We didn't have to add in most of the layers
of the pyramid because we had good organizations
in town doing that work already.
And what seems to be one of the challenges
that we're gonna face, and some of that just has to do
with how spread out people are,
in terms of density and how feasible it is
to have programs like that,
is so far, it's not seeming as easy
to identify those kinds of partners
who can help us out with all the other components
of that multi-component model that you need
to have an effective intervention.
And some of that is just because
of where our attention has been focused for years.
And so that could be conceivably recreated
in those areas, but some of it is because of
just the logistics of even trying to get that going
at all, in those areas.
- [Audience] I know you're talking about LARC,
but (no mic pickup).
How to support who are using those methods
(no mic pickup) as barriers.
(panel laughing)
- I don't even want to go there.
- [Andy] I'll repeat the question
while everybody's thinking.
So what's the research on how to help people
to be more effective at using the methods
in the middle row of the Bedsider chart, there,
to help them be more effective with those,
or maybe even the bottom ones.
- So Selena suggested that I talk about,
there's a study that we use within the LARC talks,
it just talks about like birth control pill
continuation rates.
It's a study of college women,
so women in college who know they're a part
of this study, so that they know they're being tracked.
Their pills are being monitored, like metered,
whenever they pop a pill.
And within the first month,
about a third of the women in that study
were missing three or more pills a month.
And by the third month in the study,
over half were missing three or more.
So, knowing their method isn't
(audio drops) know like we know.
We know that obviously, the LARC methods,
but there are still people.
And the birth control pill is like,
when you say birth control,
that's what people think, you know?
So, there are obviously still people
who choose these methods.
Bedsider is a really great resource.
They have like alarm reminders
to remind you to, whatever your method is,
you can just plug in when you started it,
and it will remind you, daily for the pill.
For the shot, it'll remind you when you need to go back,
stuff like that.
So that's like one method.
Just telling, like use your phone,
like if this is what you're going to choose,
but also like being realistic about it.
You know, when we talk about these methods,
I like to be honest.
Like, I don't remember to take my vitamins every day.
I don't always remember to make my bed every,
you know, like just being honest
about not everyone is regimented in that way.
So you need to be, like have that awareness.
And with any of the methods, we also need
to honor people when they decide,
you know, they're deciding what they think will work
for them, and if they get to a point that something
isn't gonna work for them,
even if it's a LARC method, respecting
that they want that removed.
Or like, if it's a method that they've tried,
and they're not being able to maintain,
they totally have that right to look into something else.
But there are definitely reasons why,
you know, some people might feel
there's like an invasive level or something like that
with the LARC methods, and--
- [Andy] And they're different things
that medical providers can do.
They could make it easy to start on the pill, for example.
(no mic pickup)
It's a bit off topic for this,
but there is research on different things
that can be done to facilitate.
But from a public health standpoint,
the big message is still that passive prevention methods
are just as a rule, gonna be more effective
than active prevention methods.
And so LARC is a passive prevention measure,
because once you get it put in,
you don't have to actively do anything every day,
as opposed to things like the pill.
Alright, I think we're about out of time,
and that was a lot of questions,
so thanks everybody.
(audience applauding)
- Thank you, so much.
That was really an excellent presentation,
and I hope everybody'll come back and join us
at the next Public Health Grand Rounds,
and that you will also consider including
this talk in any talks you might be doing
in the community or that,
if you think of good places where the group could go,
we'd appreciate it.
Thanks so much, and be sure to fill out
your evaluation form.
That was great, thank you so much, Andy.
(audience chattering)
Thank you guys, that was really great.