Bridging the Gap: A Contraception Counseling Workshop for Healthcare Professionals

Background: Unintended pregnancy is a major public health issue in the United States. Physicians and allied health professionals play a principal role in providing current, accurate, and unbiased reproductive health information. The Medical Students for Choice chapter leadership at Touro University-California identified the public health implications of accessible contraception, the discussion of all-current contraceptive methods, and effective contraception options counseling as gaps in the current curriculum. This paper describes the process of creating, implementing, and evaluating a collaborative, hands-on contraception workshop conducted in order to address these deficits. Methods: Forty-two students from the osteopathic medicine, physician assistant, and public health programs attended the workshop. All attendees agreed to participate in preand post-intervention evaluation, which assessed changes in knowledge and attitude as well as collected acceptability information. Results: This workshop achieved its goal of increasing knowledge about contraception and contraception options counseling. While attitudes about the importance of contraception information in curriculum and the likelihood of using contraception options counseling skills in the future did not significantly change, they were high to start with and they trended in a positive direction. Conclusions: This workshop has the potential to inform the development of similar contraception workshops in medical or allied health profession programs with similar curricular deficits. Improved training preclinical contraception training has the potential to optimize women’s contraception counseling experiences and help reduce the high number of unintended pregnancies in the United States.


Introduction and Background
It is estimated that there are 62 million women in their childbearing years, ages 15-44, in the United States (CDC, 2009).On average, a couple in the United States desires two children (Guttmacher, 2000).In order to achieve this goal, the average woman spends approximately five years pregnant, postpartum or trying to conceive, and three decades using a form of contraception (Guttmacher, 2000).
Unintended pregnancy is a major public health issue as 49% of pregnancies in the United States fall into this category (Finer & Henshaw, 2006).Individuals at risk of unintended pregnancy are those of reproductive age who do not desire children.Two-thirds of women in the US who are at risk for unintended pregnancy use contraception consistently and correctly.These women account for only 5% of all unintended pregnancies each year as a result of contraception failure.In contrast, 19% of women at risk use contraception inconsistently or incorrectly.These women account for 43% of all unintended pregnancies each year.Last, 16% of women at risk do not practice contraception at all for a month or more during the year.These women account for 52% of all unintended pregnancies (Gold, 2009).
Reducing the unintended pregnancy rate is a national public health goal.Over the next 10 years, the U.S. Department of Health and Human Services' Healthy People 2020 campaign aims to reduce unintended pregnancy from 49% to 44% (Healthy People 2020, 2011).The campaign aims to achieve this goal by increasing access to contraception counseling, eliminating the need for prescriptions for contraception, and increasing correct use through information dissemination by clinicians.
As a result of increased specialization in all health fields, clinicians and public health professionals are not all exposed to comprehensive reproductive health information during their training.During medical school and graduate programs, students may be exposed to the topics of family planning and contraception but not all schools have comprehensive reproductive health information in their curriculum.This gap is surprising given that, regardless of specialty, almost all healthcare providers will care for women of reproductive age (Herbitter et al., 2011) and an estimated 56% of women rely solely on their health care providers for information about contraception (Smith, Gilliam, Leboeuf, Neustadt, & Stulberg, 2008).
The Accreditation Council for Continuing Medical Education (ACGME) and American Osteopathic Association (AOA), the governing bodies of medical education recognize that clinicians and public health professionals play an important role in providing accurate and unbiased reproductive health information to patients.Thus they have set standards that require the discussion of contraceptive methods in reproductive health curricula.Despite these efforts, comprehensive contraception education is often lacking in the curricula of many health professional programs.A survey conducted at 77 medical schools found that contraception is covered at 96% medical school during preclinical training (Steinauer et al., 2009).Yet not all methods are covered equally.Oral contraceptive pills (OCP) are covered in 95% of programs despite being one of the less effective methods of contraception, while intrauterine devices (IUDs) are only covered in 59% of programs despite being one of the most effective (Steinauer et al., 2009).Furthermore, only 26% of the schools surveyed addressed major determinants of patients' abilities to access a method of contraception including acceptability, policy, and law.(Steinauer et al., 2009).
Current research focuses primarily on identifying the gaps in reproductive health curricula and assessing student values regarding these deficits, but little has been done to evaluate easily replicable options to address these discrepancies (Steinauer et al., 2009).
This study aims to test and evaluate a workshop-style contraception curriculum enhancement program for graduate students in clinical and public health programs at one university in California.The primary objective of this study is to evaluate how knowledge and attitudes about contraception change after a collaborative, hands-on contraception workshop, in which students learn comprehensive, medically accurate, and unbiased contraceptive methods information and basic contraception options counseling techniques.
Secondary objectives include gathering acceptability information that has the potential to inform the development of similar contraception workshops in clinical and public health programs with comparable curricular deficits.

Development of the Comprehensive Contraception Workshop
Using the American Reproductive Health Professionals (ARHP) Medical Student Curriculum Guide as a reference, the MSFC chapter leadership at TUC identified the discussion of current contraceptive methods, contraceptive options counseling, and public health implications of accessible contraception as gaps in the pre-clinical curricula (AHRP Medical Student Curriculum Guide, 2006).
A presentation from the ARHP Curricula Organizer for Reproductive Health Education (CORE) program, an openaccess database of peer-reviewed, evidence-based teaching materials and a Planned Parenthood contraception options counseling training presentation were used to develop the workshop teaching material.Two primary care faculty members reviewed the final workshop presentation and handouts for comprehensiveness and accuracy.Donations of pharmaceutical samples of each of the current methods of contraception were solicited from the local Planned Parenthood training department and obstetrics and gynecology practices.At least one sample of every current contraceptive method was collected in addition to the clinical IUD insertion training models already available through the pre-clinical primary care department at TUC.Two primary care department faculty members and an outside contraception-counseling staff trainer from the local Planned Parenthood affiliate helped facilitate the workshop.

Comprehensive Contraception Workshop Description
The workshop and evaluation was conducted on at Touro University at California.The workshop consisted of four thirty-minute segments.The first thirty-minute segment was a didactic session designed for a group of 45 students.The following three thirty-minute segments were hands-on stations designed for interdisciplinary groups of 15 students as shown in Table 1.Each station provided handouts and information sheets specific to the contraceptive methods discussed.Attendees also had the opportunity to download the handouts prior to the workshop for those who preferred electronic versions.
The stations were led by student organizers, TUC faculty, and a contraception counselor affiliated with Planned Parenthood.The stations presented an example of each contraceptive method along with associated side effects, health benefits, and counseling strategies to cover both patient information and methods to promote contraceptive continuation.Notable health benefits and risks include the fact that hormonal contraception has been shown to reduce the risks of endometrial and ovarian cancer, whereas the risks of breast, cervical, and liver cancer are slightly increased (Burkman, 2004).

Evaluation and Data Collection
The pre-and post-intervention evaluation component of the workshop received an exempted status by the TUC Institutional Review Board (IRB) Committee.In order to participate in the evaluations, each student was required to attend the two-hour workshop.The evaluations were not mandatory and students were welcome to participate in the workshop regardless of their evaluation participation.
Participants received no direct compensation for completing the evaluations and time was allotted at the beginning and the end of the workshop so that evaluation participation did not place any burden on the attendee's time.
All data was entered into an Excel worksheet with no personal identifiers.All quantitative statistical measurements were completed in Small Stata 13.0.All fill-in answers were entered into the worksheet and then coded by keywords.

Demographics
Overall 51 students signed up to attended the contraception workshop, 42 students attended, and 100% of attendees agreed to participate in the evaluation.The degree programs represented were as follows: 21 first and second year DO students, 10 first and second year students who were pursuing a dual DO/MPH degree, 5 students from the MSPAS/MPH program, and 6 students form the Independent MPH program.Two DO/MPH students completed the pre-intervention evaluation but did not complete the post-intervention evaluation.

Contraception Curriculum Experience
Of the students in attendance, 57% had experienced at least one lecture on contraception included in their respective degree programs.
A second-year osteopathic medical student noted: "We had a one-hour lecture during our reproduction unit.It's hard to learn about all the different methods without seeing each one." Another second-year osteopathic medical student chose not to attend the lecture: "We had one lecture on contraception.It was at 8 in the morning and I did not attend, but I read the PowerPoint [presentation].I'm here to get all the information that wasn't covered in the [PowerPoint] slides." A physician assistant student commented: "The lectures were good, but I would never feel comfortable giving contraceptive advice to patients, or even friends at this point.I need more information before [clinical rotations]"

Future Areas of Practice
Attendees were asked to select the area, or areas, of practice they might pursue after graduation.Of the students in attendance, 74% responded that they were interested in working in the primary care field and 60% of attendees responded that were interested in obstetrics and gynecology.Furthermore, 67% of attendees indicated they planned to include aspects of community public health focused locally in United States in their future practice, while 36% indicated that they would like to focus on global public health issues.

Contraception Workshop Attendance
When attendees were asked which of the following reasons best describes why they chose to attend a non-mandatory contraception workshop, 90% stated that they attended in order to learn about the current methods of contraception.
Nearly the same number, 85% of attendees, report that that they attended the workshop in order to learn how to counsel patients on all current contraception options.Additionally, 62% of attendees reported that they were in attendance in order to dispel myths about contraceptive methods; while 57% of reported that they were in attendance to learn contraception information for themselves or their partners.

Reasons for Attending the Contraception Workshop (Respondents asked to choose all that apply) %
To learn more about current contraceptive methods 90%

Reasons for Attending the Contraception Workshop (Respondents asked to choose all that apply) %
To learn how to counsel patients about all current contraception method options 86% To dispel methods about current contraceptive methods 62% To learn more about their own or their partners own current contraception method options 57%

New Information
When asked which segments of the workshop offered largely new information, 90% of attendees indicated station three, which covered LARCs including IUDs and contraceptive implants, as well as sterilization, and emergency contraception.Station one, station two, and the public health introduction were indicated by 53%, 55%, and 50% of attendees respectively

Importance of Contraception Information in Curriculum
In order to assess attitude changes over the course of the workshop, attendees were asked on both the pre-and postintervention evaluations to rate the importance of including contraception information in their respective TUC curricula.
This factor was assessed using a 5 five-point Likert scale with 1 indicating 'not important to include contraception information', 3 indicating it is 'of some importance to include contraception information, and 5 indicating it is 'very important to include contraception information'.
Prior to the intervention, 32 individuals, or 76% of attendees rated the importance of including contraception information in their respective TUC curricula as a 5, indicating that they felt that it was 'very important to include contraception options information'.After the intervention, this number increased to 35 individuals, or 87% of attendees.
Prior to the intervention 4 individuals, or 10% of attendees, indicated the importance of including contraception options information in their respective TUC curricula as a 2 or 3. Yet after the intervention every attendee rated the importance of including contraception options information in their respective TUC curricula as a 4 or a 5.

Likelihood of Using Contraception Options Counseling
In order to assess attitude changes over the course of the workshop, attendees were asked on both the pre-and postintervention evaluations to rate the likelihood they would use contraception options counseling skills in their future career.
This was assessed using a 5 five-point Likert scale with 1 indicating 'not likely at all', 3 indicating 'somewhat likely', and 5 indicating they were 'very likely' to use contraception options counseling skills in their future career.
Prior to the intervention, 35 individuals, or 83% of attendees felt that it is 'very likely' they would use contraception options counseling skills in their future career.After the intervention this number increased to 36 individuals, or 92% of attendees.

Change in Knowledge IUD Safety and Acceptability
To assess knowledge changes over the course of the workshop, attendees were asked on both the pre-and postintervention evaluations to agree or disagree with the statement, 'Most women, regardless of age, monogamy, or having given birth are good candidates for an IUD'.Attendees were also given the option to write a brief statement explaining their answer choice.
Prior to the intervention, 29 individuals, or 68% of attendees, indicated that they agreed with the statement, while 13 individuals, or 32% of attendees, indicated that they disagreed with the statement.After the intervention, 100% of attendees indicated that they agreed with the statement (p=0.000).

Risk of Cancer in Women Using Hormonal Contraception
In order to assess knowledge changes over the course of the workshop, attendees were asked on both the pre-and post-intervention evaluations to agree or disagree with the statement 'Using a form of hormonal contraception increases a woman's risk of cancer'.Attendees were also given the option to write a brief statement in place of agreeing or disagreeing with the statement.
Prior to the intervention, 15 individuals, or 35% of attendees agreed with this statement, 12 individuals, or 29% of attendees disagreed with this statement, and 15 individuals, or 35% of attendees chose to write in their own answer.
After the intervention, 3 individuals, or 8% of attendees agreed with this statement, 30 individuals, or 75% of attendees disagreed with this statement, and 7 individuals, or 35% of attendees chose to write in their own answer (p=0.000).
Of the written answers, prior to the intervention, a second-year osteopathic medical student noted: "I know the effect varies for different kinds of cancer, but that is all I remember from our lecture a few days ago." Also prior to the intervention, a physician assistant student wrote: "That's what I've heard, but I have no idea if it is actually true.Hopefully I'll find out today." After the intervention, one independent MPH student noted: "It depends on what type of cancer you are talking about-I learned today that it decreases the risk of ovarian and endometrial cancer." Furthermore, after the intervention a first-year osteopathic medical student noted: "I learned that it varies with the type of cancer-there is an association between nulliparity and breast cancer, so one could say that contraception does increase this risk."

Perceived Knowledge of Contraceptive Methods
In order to assess knowledge changes over the course of the workshop, attendees were asked on both the pre-and post-intervention evaluations to rate their perceived knowledge of contraceptive methods.
This was assessed using a 5 five-point Likert scale with 1 indicating 'no knowledge of current contraceptive methods", 3 indicating 'moderate knowledge of current contraceptive methods, and 5 indicating 'knowledgeable about all current contraceptive methods'.
Prior to the intervention 10 individuals, or 24% of attendees, reported their knowledge to be a 1 or a 2 indicating that they had little to no knowledge of current contraceptive methods, 32 individuals, or 76% of attendees, reported a 3 or a 4 indicating moderate knowledge of current contraceptive methods, and no attendees reported a 5 indicating knowledgeable about all current contraceptive methods.
After the intervention, no attendees reported their knowledge to be a 1 or a 2 indicating little to no knowledge of current contraceptive methods, 17 individuals, or 42% of attendees, reported 3 or a 4 indicating moderate knowledge of current contraceptive methods, and 23 individuals, or 58% of attendees, reported a 5 indicating knowledgeable about all current contraceptive methods.The difference between learners reporting a 1 or 2 versus the number of learners reporting a 3, 4, or 5 prior to and after the intervention was statistically significant (p=0.001).

Perceived Knowledge of Contraception Options Counseling Knowledge
In order to assess knowledge changes over the course of the workshop, attendees were asked on both the pre-and post-intervention evaluations to rate their perceived knowledge of contraception options counseling.
This was assessed using a 5 five-point Likert scale with 1 indicating 'no contraception options counseling knowledge', 3 indicating 'some contraception options counseling knowledge', and 5 indicating 'very good contraception options counseling knowledge'.
Prior to the intervention 26 individuals, or 62% of attendees, reported their knowledge to be a 1 or a 2 indicating that they had little to no contraception options counseling knowledge, 16 individuals, or 38% of attendees, reported a 3 or a 4, indicating at least some contraception options counseling knowledge, and no attendees reported a 5 indicating very good contraception options counseling knowledge.
After the intervention 5 individuals, or 12% of attendees, reported their knowledge to be a 1 or a 2 indicating that they had little to no contraception options counseling knowledge, 22 individuals, or 55% of attendees, reported 3 or a 4, indicating at some contraception options counseling knowledge, and 13 individuals, 33% of attendees reported a 5 indicating very good contraception options counseling knowledge (p=0.000).

Discussion
This workshop achieved its goals of increasing knowledge about contraception and contraception options counseling.While attitudes about the importance of contraception information in curriculum and the likelihood of using contraception options counseling skills in their future career did not significantly change, they were high to start with and they trended in a positive direction.
Of the individuals in attendance, 90% indicated that they attended the workshop in order to learn about the current methods of contraception and 86% indicated that they attended the workshop in order to learn how to provide contraception options counseling.This reflects the value the attendees place on these important skills.Interestingly, 62% of attendees indicated that they attended the workshop in order to dispel myths about contraceptive methods.This may indicate attendees may be aware of confusion and misinformation around contraception.Lastly, 57% of attendees indicated that they attended the workshop in order to learn about contraception information for themselves or their partners.Even graduate students may not be receiving adequate contraception options counseling from their health care providers or other sources of reproductive health information.
Notably, only 57% of attendees report having attended a lecture on contraception in their respective curricula.This is a relatively low number considering all workshop attendees, except for some MPH students, have at least one contraception lecture included in their TUC curricula.This may be because students have not yet reached the contraception lectures in their respective programs.Specifically, osteopathic medical students receive their one-hour lecture in the second year.Thus any first year attendees would not yet have attended a lecture.Additionally, some students chose not to attend their non-mandatory lecture on contraception.The osteopathic medical program holds their one-hour lecture at eight in the morning-a time of notoriously low attendance for non-mandatory lectures on any topic.
Importantly, this workshop ensured every attendee left with a baseline knowledge of all methods of contraception as evidenced by the fact that post-intervention no attendees reported their knowledge to be a 1 or a 2 indicating that they had little to no knowledge of current contraceptive methods.Specifically, respondents felt they knew the least amount about LARCs and demonstrated significant increases in knowledge in the pre-post evaluation.While over half of attendees report having already attended a lecture on contraception in their curricula, 90% of attendees felt that station three, LARCs, sterilization, and emergency contraception, offered largely new information.This is consistent with previous data indicating that newer, more effective methods and emergency contraception are not being covered adequately in the current curricula (Steinauer et al., 2009).
Knowledge about IUD safety and acceptability changed significantly after the intervention.Prior to the intervention 32% of attendees did not agree with the statement, 'most women, regardless of age, monogamy, or having given birth are good candidates for an IUD.' Lingering confusion and stigma about IUDs in this group may be a result of the Dalkon Shield failure in the 1980's.After an evidenced-based discussion of IUDs and demonstration of proper IUD insertion techniques, 100% of participants agreed with the statement.Clarifying this important information in the pre-clinical years may result in better future patient care.
It was also clear from this evaluation that the risk of cancer in women using hormonal contraception is a point of confusion.While most attendees reported that they did not know the answer to the question about cancer, they were more likely to demonstrate their understanding of the variation in risk among different types of cancer in the post evaluation.This may have implications for attendees who go on to provide contraception counseling and patients with a misplaced fear of increased cancer risks.
This intervention also provided over half of attendees with their very first experience with contraception options counseling, which was identified as a deficit in in the current curriculum.Prior to the intervention, 62% of attendees indicated that they had little to no contraception options counseling knowledge and after the intervention 12% of attendees, reported they had little to no contraception options counseling knowledge.
It also demonstrated positive attitude trends regarding the importance of contraception information in their respective curricula and the likelihood of using contraception options counseling skills in their future career.

Limitations
Limitations to the evaluation include a selection bias as a result of the opt-in format of this workshop and targeted advertising to reproductive health focused interest groups.This may lead to an underestimation of the attitude and knowledge changes due to the fact that attendees generally had a positive attitude towards including contraception information in their respective curricula, planned to use contraception options counseling in their future careers, and had a high perceived knowledge of contraceptive methods.Further evaluation of a larger, more diverse cohort, accomplished by advertising to a wider variety of student interest groups will help decrease the selection bias which may lead to an underestimation of the attitude and knowledge changes.
In addition, the pre-intervention and post-intervention surveys were not matched, which did not allow for assessment of individual changes with respect to the intervention.Matched pre-intervention and post-intervention evaluations will provide information about individual knowledge and attitude changes and allow more specific assessment of each program at TUC.
The small sample size and the pre-post study design also limit the ability to make causal statements about the impact of this workshop.

Conclusion
It is crucially important for healthcare professionals to be exposed to accurate comprehensive reproductive health information during their training.This small group, interactive workshop is an effective way to expose students to contraception options and counseling strategies.By adopting this educational model as a supplement to current curriculums, faculty and students can greatly improve contraceptive outcomes for women.

Take Home Messages
Contraceptive counseling and public health significance of contraception methods are lacking in health-care focused schools Unintended pregnancy is a major public health issue; physician competency in contraception counseling can prevent unintended pregnancies Student led initiatives can influence health-care education curricula Medical student efforts generate effective and educational workshops Hands-on contraceptive training can improve student physician knowledge on contraceptive counseling

Notes On Contributors
Lauren Sobel, DO/ MPH, was the President of the Medical Students for Choice, Touro University-California Chapter.
Brenna Sommer, DO, was a member of the Medical Students for Choice, Touro University-California Chapter.
Catherine Shea, DO, was a member of the Medical Students for Choice, Touro University-California Chapter.

Table 1 :
Workshop Organization

Table 2 :
Pre and Post-Intervention Attendee Demographics

Table 3 :
Contraception Workshop Attendance

Table 4 :
Stations Which Offered Largely New Information (Caro-Bruce, Schoenfeld, Nothnagle, & Taylor, 2006)rticularly large challenge is ensuring sustainability of a studentdeveloped workshop.Strong student-faculty partnerships are necessary to sustain student developed curricula, as has been demonstrated previously in a student-initiated elective on sexual health(Caro-Bruce, Schoenfeld, Nothnagle, & Taylor, 2006).This has been addressed by sharing the lecture and handout materials with the incoming leaders of the MSFC campus chapter and Obstetrics and Gynecology Interest Group.Additionally, a complete set of current pharmaceutical contraception models including IUD insertion training kits has been assembled and donated to the TUC Primary Care Department for future students use.This model has already shown success and sustainability, as it is being replicated by the incoming MSFC chapter leaders at TUC.This educational model is designed to be easily replicable and has the potential to inform the development of similar contraception workshops in clinical or public health programs with comparable curricular deficits.Improved preclinical contraception training will result in more comprehensive, medically accurate, and unbiased patient counseling.Offering this model of training in medical schools is one strategy to optimize women's contraception counseling experiences and prevent unintended pregnancy.