Prepare family planning patients for successful pill-taking
Help patients make contract with themselves to use method
You've taken a lengthy history, reviewed the contraceptive opt-ions, and handed your patient her first set of birth control pills and a standard instruction sheet. Is she now adequately protected against pregnancy? She is - if she takes the pills on a regular basis. When used correctly, oral contraceptives (OCs) are more than 99% effective. This high level of efficacy drops, though, when women miss pills or experience a side effect that leads them to stop using the method.
Patient/provider interaction before the prescription is written may make the difference in whether success will be achieved in consistent pill taking, say those who have conducted research on OC compliance. By individualizing your questions to the woman sitting in front of you, discussing the transient nature of most side effects, and identifying protective strategies when pills are missed, you can serve as the catalyst that sets your patient on the road to successful contraception.
A study published in 1995 of more than 6,000 women who had used OCs found that of those who reported inconsistent pill use, 47% said they didn't receive enough information on the method when it was prescribed.1 Take a look at how you inform your patients. Is it an example of what researcher Deborah Oakley, PhD, calls the "VCR phenomenon"? Oakley, professor of nursing at the Center for Nursing Research in the School of Nursing at the University of Michigan in Ann Arbor, explains: "We did a study that tape recorded the whole clinic visit.2 What we found in content analyzing was that the nurses do not give individualized care, and they don't do much assessment about the ability to carry out the job once the client has left. I call it the VCR phenomenon: The tape goes in, and the same thing comes out. It gets played no matter who presents."
Ask questions about how your patients plan to use the pills, and tailor each question to their responses, Oakley says. "These questions need to deal with the future and not the past. They need to deal with specific behaviors such as taking a pill every day; figuring out what the person is going to do when she does miss a pill, so she learns how to build into her repertoire; and the ability to recognize when she's missed pills and then to change her pattern in some way or ask for a different method."
Information sheets are good starting points for talking about OC use, but move forward in individualizing the information to make it relevant for the patient, says Michael Rosenberg, MD, MPH, clinical professor of OB/GYN and epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private medical research firm in Chapel Hill.
If you rely on written educational handouts, review them to see if they are written in clear, concise language, offers Linda Potter, DrPH, visiting research collaborator with the Office of Population Research at Princeton University. Since about 40% of all Americans are unable to read and follow instructions, you will need to review information with your patients to make sure they understand it, she notes.
Oakley sees the goal of the provider as facili-tating the process so the patient leaves with a contract with herself to use the method. In this model, the provider serves as more of a facilitator and catalyst rather than a teacher or instructor. "Some of our nursing texts and the new guidelines use the word `instruct,' which drives me crazy," she says. "It's telling - talking to a person - and actually, there has to be more question asking."
Side effects with OCs can, and do, happen. Bleeding and spotting are leading reasons for calls and unscheduled visits to providers.3 Review the side effects that may occur so patients will be prepared, says Rosenberg. "I think with the low dose preparations that we deal with now, it's very important to talk about the possibility of spotting and bleeding. When that happens, if you don't expect it, it's a big deal. I think that makes women drop these pills fairly quickly."
Counsel women that such side effects may indeed signal a missed pill, says Susan Wysocki, RNC, BSN, NP, president of the National Associ-ation of Nurse Practitioners in Reproductive Health in Washington, DC. If spotting or bleed-ing do occur, have them check their pill packs.
Side effects can lead to method discontinuation and unintended pregnancy. Remind patients that most side effects are transient, and they should use a backup method or abstain from intercourse if they lapse in pill-taking.
Missed pills happen
Accepting the fact that missed pills happen is important for both patients and providers, Wysocki advocates. "Women miss pills, and I don't always pay my bills on time, because life is unpredictable and hectic. Clinicians need to understand that missing pills is the norm, so we can adjust our teaching to address it."
A study by Oakley, Potter, and two researchers from Family Health International of Research Triangle Park, NC, showed that half of its population recorded missed pills.4 Using a special pill pack device with a computer chip to record the missing pills, researchers matched the results against self-recorded diaries kept by study participants. The comparison showed that the participants under-reported the number of missed pills.
Since missed pills happen, help women identify upfront strategies to ensure good pill-taking and to take action when they forget, Wysocki says. Provide an extra pill pack to tuck in a purse or overnight bag so they won't be caught short.
Identify a backup method and explain when and how to use it. Only a few women in Oakley and Potter's study consistently used backup contraception after a missed-pill episode.4 If a backup method isn't used, explain the need for abstaining from intercourse. Also include information about emergency contraception during counseling.
Rosenberg's research firm is now investigating a new oral contraceptive that will shorten the hormone-free interval from seven to two days. "Our study is going to be completed by the end of the year. It's a study that is specifically intended to see what these pills look like in real day-to-day use." (Contraceptive Technology Update will report results as they become available.)
Potter, along with James Trussell, PhD, director of the Office of Population Research at Princeton University (NJ) and associate dean of the university's Woodrow Wilson School of Public and International Affairs, has been working on revising the form of the packaging insert included with OCs to make it more user-friendly. A draft of the proposed document is now under review by the U.S. Food and Drug Administration, Potter says. (An overview of proposed changes in the packing insert will appear a future issue of CTU.)
When you counsel a woman on oral contraceptives, recognize the role of the partner in successful pill taking. One of the predictors for increased risk of pregnancy in Oakley and Potter's study was receiving low partner support for pill use.4
Get partners more involved in the whole process of care, Oakley suggests. If a partner is out in the waiting room, consider inviting him in during the counseling session.
"If our findings can be generalized that partner support in using a method is important, then our providers are giving no help," she says. "They probably are not talking very much with the women about how they can negotiate more effectively with their partners, and [providers] also are saying partners are not that important by not including them in the visit."
References
1. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives; risk indicators for poor pill taking and discontinuation. Contraception 1995; 51:283-288.
2. Dodge JA, Oakley D. Analyzing nurse-client interactions in family planning clinics. J Commun Health Nurs 1989; 6:37-44.
3. Hillard PJ. The patient's reaction to side effects of oral contraceptives. Am J Obstet Gynecol 1989; 161:1,412-1,415.
4. Oakley D, Potter L, de Leon Wong E, et al. Oral contraceptive use and protective behavior after missed pills. Fam Plann Perspect 1997; 29:277-279, 287.
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