Integrating Long Term Reversible Contraception Services In New York City School-based Health Centers: Quality Improvement to Ensure Provision of Youth-friendly Services

Abstract

In 2007, the American College of Obstetricians and Gynecologists (ACOG) recommended Long Acting Reversible Contraception (LARCs) including intrauterine devices (IUDs) and implants as first line contraception for adolescents. In March 2015, seven School Based Health Centers (SBHCs) providing comprehensive primary care to youth in New York City public schools began offering a full range of LARC services in the SBHCs operated by New York-Presbyterian Hospital. The goal of this quality improvement (QI) project is to identify strategies to ensure quality of care before, during, and after providing LARC services. As part of QI efforts, we conducted interviews with female adolescents who received LARC services at three SBHCs in the first 6 months of the initiative. Between March and August 2015, 55 patients received LARC services; all were given the opportunity to be called to participate in a QI interview related to their LARC procedure. IRB approval from Columbia University Medical Center and the Department of Education was waived for this QI project. A total of 44 consented to participate and, to date, 18 completed a structured 30-item interviews. Data was analyzed using NVivo. A coding guide of themes and outcomes were structured to correspond to Ambresin’s 8 domains of youth-friendly services: accessibility, staff attitude, communication, medical competency, guideline-driven care, age-appropriate environment, involvement in healthcare, and health outcomes. Within these 8 domains, we identified emerging themes using grounded theory, with a focus on specifying aspects of care that participants found useful and practical suggestions for improving LARC services in SBHCs. Two independent reviewers coded the data with resolution of discrepancies by consensus and a third reviewer. The 18 participants ranged in age from 15 – 19 (average: 17 years.) Participants could have more than one procedure during the QI period; most had insertion procedures (12 IUDs, 5 implants), 1 had a removal (IUD) and 1 had an unsuccessful IUD insertion. Overall, participants were highly satisfied with SBHC LARC services. Maintaining privacy of services emerged as a key theme. Within the domain of communication, two key themes emerged: balancing the need for information with concerns about being overwhelmed by information; and interest in information that directly addresses myths and misconceptions about LARCs. Suggested strategies in the domain of communication included providing post-procedure “care packages” with information and supplies, and supporting a peer-based, information sharing network of patients who received LARC services to be available as a resource for patients interested in LARCs. This QI project, conducted in a unique setting, was designed to give adolescents a voice and garner feedback to the SBHCs where they receive care. Results include strategies for QI in health education, social support, and school-based outreach that can be generalized to SBHCs across the USA. Findings also provide paths for future research to explore the impact of implementing suggested strategies on reproductive health outcomes at SBHCs.