Systems

0:00:40.5 Professor Walden: I should have figured this out, because I couldn’t hear yesterday. How are you?

0:00:45.1 Janelle King: I’m good. How are you?

0:00:47.1 Professor Walden: You can hear me. I definitely cannot hear you. I don’t know what the deal is.

0:00:51.6 Janelle King: You can’t?

0:00:52.1 Professor Walden: And it’s my end. It’s not you. Okay, let’s see. Let’s see, if I can just… I don’t know why my sound is wanting to be very funny today. There we go.

0:01:18.1 Janelle King: Can you hear me?

0:01:19.2 Professor Walden: I can hear you but then I cut…

0:01:20.2 Janelle King: Perfect.

0:01:21.0 Professor Walden: My face off of course. There we go. Fantastic.

0:01:25.7 Janelle King: I’m gonna turn this down a bit.

0:01:28.6 Professor Walden: How are you doing?

0:01:29.2 Janelle King: I am pretty good for it, what day is it? Saturday?

0:01:34.1 Professor Walden: No, I know Saturday, I’m working, I’m in the office. I apologize.

0:01:39.7 Janelle King: No worries, no worries. It’s all worked out, so…

0:01:44.3 Professor Walden: Right.

0:01:45.3 Janelle King: I was over here like, “Let me figure this out over here,” ’cause I’m not at home, I’m at the library, just ’cause I was like, “Let me just go to a space where I know my family is not gonna bother me,” so…

0:01:54.7 Professor Walden: No, I understand.

0:01:56.2 Janelle King: I’m trying to figure out the logistics over here, so…

0:02:00.0 Professor Walden: Same, I am not in my usual… I am at my physical office, not my home office, which is what I use for these.

0:02:06.0 Janelle King: Gotcha.

0:02:07.6 Professor Walden: So I’m always like, “I don’t know what’s happening. “

0:02:11.6 Janelle King: Now, let me see if I can figure… So I’m not the best techie so maybe it’s around there. Let’s do it that way. So let me…

0:02:20.8 Professor Walden: Yes, let me allow you to do it. So that’s kind of… While you’re figuring that out, I’ll kinda tell you. How it’ll go.

0:02:26.8 Janelle King: Okay.

0:02:27.6 Professor Walden: So I’ll do a little… While it’s recording right now. I think we will trim it all up and stuff like that. So…

0:02:34.3 Janelle King: Okay.

0:02:35.7 Professor Walden: I’ll do a little intro and then you’ll just kind of be sitting there and then you’ll start talking, “Hello.” As I… After I introduce you, ’cause I’m gonna read your bio.

0:02:48.1 Janelle King: Okay.

0:02:49.7 Professor Walden: And then you can basically start your screen share and kind of in your way.

0:02:54.3 Janelle King: Okay.

0:02:54.5 Professor Walden: What I usually do is I will turn off my camera because I don’t want to be a distraction as well during your lecture.

0:03:02.2 Janelle King: Right.

0:03:05.1 Professor Walden: And clearly, I’ll be here listening, but as you begin to wrap up, I will… And I will hear you, I will pop back in, we’ll do a little… Usually a dialogue. Usually it’s some things that you said that I want to reinforce, and then we’ll wrap up and go from there.

0:03:23.0 Janelle King: Okay, I think I’m in the wrong… Let me go back to my other account, I’m sorry, this is taking longer than it needs to. Well, thank you, so… I just wanna thank you for the opportunity. I was like, “You know, I’m not an NP, right? You guys are well aware that I’m not a provider.” So…

0:03:43.1 Professor Walden: No, no, no, we understand, but we like what you do, so…

0:03:47.9 Janelle King: Oh, thank you.

0:03:50.0 Professor Walden: We like what you do.

0:03:51.7 Janelle King: Okay, so let’s see if this is going to work here, and hopefully this is the right… Version 214. Okay, and so let me get back to you. And hopefully that is what I need to be.

0:04:17.1 Professor Walden: No, we’ve got two non-tech savvy people, figuring out… I get it. That’s okay. Alright. Are you ready?

0:04:30.5 Janelle King: I am ready.

0:04:33.6 Professor Walden: Okay, fantastic, so I’m gonna put this part here. As soon as I say, “Are you ready?” My computer starts to fall. It will be a great day I can tell.

0:04:50.6 Janelle King: Don’t worry, we’re gonna work through it. It’s all gonna be perfect.

0:04:51.4 Professor Walden: Keep pointing we’ll work through this.

0:04:53.2 Janelle King: It’s gonna be fine.

0:04:53.8 Professor Walden: I know, I know. Boy, I tell you, it’s been a day already. I’m just gonna put this here. Perfect. Alright. Alright, fantastic. Guys welcome. Welcome. So if you are joining us, then you know that we are very excited to have our guest, Ms. King, join us. We have been watching and learning right along with her on the inter-webs as I like to say. And so we are just excited that she’s decided to grace this with her presence today and learn us some stuff as I like to say. So I’m gonna read her bio and then you guys… We are going to bring her on and talk, and then we’ll get right to it. So Ms. Janelle King has an MPH, BSN, and an RN. And she’s a registered nurse with a Master’s Degree in Public Health.

0:05:51.9 Professor Walden: Her clinical background includes Clinical Research, HIV outreach, which we love, adolescent medicine and college health. During her nursing career, she has spent many years educating young adults about reproductive and sexual health. Janelle’s love for patient education inspired her to create and use social media platforms to educate her predominantly African-American female fan base about the vagina’s anatomy and hygiene, periods and sex. She also teaches about hormonal and non-hormonal birth control options and sexually transmitted infections.

0:06:27.4 Professor Walden: She aims to normalize taboo topics and dispel myths and misconceptions related to sexual health. Janelle believes her relatable demeanor, clinical and personal experiences help women better understand their bodies and choices. An accomplished blogger and writer, she has contributed to Women’s Day magazine, AARP Sisters Newsletter, and TheBody: The HIV/AIDS Resource, among many others. She is a Journey Award winner and has been featured on several podcasts, including Zuri’s Hall, Zuri Hall’s HOT HAPPY MESS, Femme Focus Podcast and Be Well Sis. In her spare time, you can find her writing about reproductive health and wellness on her blog, thenursenote.com, which is where we found her. All social media handles are @thenursenote. So we’ll put that back in the group so that everyone absolutely can find you. But welcome, Ms. Janelle King.

0:07:27.6 Janelle King: Thank you so so much, I really appreciate it. So let me see if I can do the screen share without messing it up here.

0:07:34.8 Professor Walden: No, you’re fine. But we’re so excited. We’re gearing up to talk about just women’s health in general, and kind of making the strong push in our group, and knowing how to do that is not something that they truly, truly embrace and teach as well in school. So it is absolutely an area that we’re diving into trying to just get more help and more resources.

0:08:03.3 Janelle King: Well, I appreciate you letting me teach your group, it’s a real honor, and I believe a lot of you guys are new practitioners. So congratulations, first and foremost. I recognize how hard that is, so kudos to you all, I know that you may be feeling a little anxious, nervous, all of the above. I’m just gonna share the information that I’ve learned along the way, and hopefully you’ll be able to get some nuggets that you can use in your practice.

0:08:31.5 Professor Walden: Fantastic, so I’m going to let you go for it, and then I will see you when we’re almost done.

0:08:39.5 Janelle King: Okay, alright. So I’m gonna speak about a subject that is near and dear to my heart, which is contraceptive counseling, specifically looking at how to engage in shared decision making for improved health equity. And so you guys have done a great job, you’re now practitioners, big responsibilities, which is great, we need more nurse practitioners. Many of you may be working in those primary care settings, so like family medicine, internal medicine, adolescent medicine. And for a lot of women, I’m gonna use the term women throughout my presentation, I recognize that it’s gendered language, but I do mean anybody with vulvas and vaginas. And so for many women, this represents the first point of contact for a lot of health concerns. And so I think in these settings, it provides an opportune time to talk about contraceptive, counseling management, the initiation, and so that’s why I wanted to present it to this group. Okay, let’s see if I can go forward here.

0:09:48.0 Janelle King: Let’s see if that will work. Okay, there we go. I’m sorry. And so I don’t have any disclosures. I’m just doing this because I believe it’s something that we all should know and love. And so the objectives for my presentation today are pretty simple, just to understand the steps of providing contraceptive counseling, recognize the history of reproductive injustices specifically in minority communities and the impact it will have on contraceptive choices. I’m going to… Or I want you to recognize barriers to implementations of counseling as well as explain strategies to promote patient adherence to contraceptive methods.

0:10:32.2 Janelle King: And so I always like to look at kind of where we are as a society, and so I wanted to take a look at the current contraceptive use specifically here in the United States. And during the years 2017 to 2019, just over 65% of women aged 15 to 49, so of reproductive age were using some form of birth control or contraception. The most common method used was female sterilization or getting your tubes tied, at 18% followed by the oral contraceptive pill. And long-acting reversible contraceptives. So that includes IUDs, the hormonal and non-hormonal IUDs as well as the arm implant Nexplanon. The use of LARCs or the long-acting reversible contraceptive was higher among women between the ages of 20 to 29, compared with younger age groups of women over the age of 40. Condom use was higher among Hispanic women and non-Hispanic Black women. And the data suggests that women… The more educated a woman is, the less inclined she used to use female sterilization as a form of contraception, and actually the pill use increases. And so I just wanted to take a moment to look at the history of contraception, specifically here in the United States.

0:11:49.6 Janelle King: So how did we get here? Where are we at? And so in the 1870s, there was a wide assortment of birth control devices available, they had condoms, sponges, douching, syringes, diaphragms, and so these were pretty widely available and women could get them from catalogues, pharmacies, dry good stores, so on and so forth. But in 1873, there was a really big law enacted which is the Comstock Law, and this specifically prohibited the sales of contraception through the mail, so limiting a woman’s ability to get access to reproductive… I’m sorry, contraceptive devices. In 1916, Margaret Sanger, and I know she’s a very controversial figure, but I still think she played an important part of contraception history in the United States. And so she opened up her first birth control clinic in Brownsville, Brooklyn in 1916.

0:12:41.7 Janelle King: She was actually jailed for being a public nuisance because she was dispensing contraceptive devices. So she was sentenced to 30 days in jail. In 1917, she began publishing Birth Control Review, which was a magazine to just educate the public about contraception. She was also responsible for founding the American Birth Control League in 1921, and she also set up the National Committee on Federal Legislation for Birth Control, which was a lobbying organization in 1929.

0:13:14.0 Janelle King: In 1936, there was a big decision, again, with the Comstock Law, so in 1936, the courts actually overturned the provision of existing provisions in the Comstock Law, making it now legal for doctors to prescribe contraception. So that was a huge win for women. And finally, in the 1960s, and this is probably what you guys are most familiar with, the first hormonal birth control pill was approved by the FDA, ushering in a new era for a reliable contraception, giving women more autonomy over their reproductive and sexual health. At first, the pill wasn’t available to unmarried minors, but there were many changes in the state laws through out the ’60s and ’70s that increased access to birth control for minors. One of the ways that birth control access was granted to minors, or one of the changes that was implemented was they now allowed doctors to provide medical care for minors without parental consent, as long as minors were deemed mentally capable of making medical decisions. In addition, there were changes specifically to the age of majority. So the Vietnam War was happening that time, they changed the legal age of majority from 21 to 18 with the passage of the 26th amendment in 1971, so that federal change allowed more women access to birth controls.

0:14:37.5 Janelle King: And finally, in 1978, one thing I just wanted to note, was the Supreme Court made a decision that states could not constitutionally place any restrictions on the advertisement, sales or distributions of contraception to individuals of any age. So that’s kind of a brief… And I say, I do mean brief history on birth control here in the United States. I did wanna actually take a look at the history of contraception in communities of color. And then historically, we know here in the United States that we have a shameful history regarding the forced sterilization and reproductive injustice, and that has led many minority women to be distrustful of contraception. The sterilization abuse of African-American women by the medical establishment actually reached its heights during 1950s and 1960s.

0:15:29.7 Janelle King: So women who were going into the hospital to deliver children actually came out unable to have any more children. During the ’70s, sterilization or getting your tubes tied became the most rapidly growing form of birth control in the United States, increasing from 200,000 cases in 1970 to 700,000 cases in 1980. Blacks to the south, and women were routinely sterilized without their informed consent for no valid reason, and it was so widespread that it became known as the Mississippi appendectomies. During the ’60s and ’70s, poor black women were coercively sterilized under federally funded programs. So these women were threatened with the termination of their welfare benefits, denial of medical care if they didn’t consent to procedures.

0:16:17.9 Janelle King: And so one of the big things that happened was in 1973, there was a coercive sterilization of two African-American sisters, they were young, they were 12 and 14. This actually sparked a lawsuit and a national campaign to end sterilization abuse. There was a committee formed, the Committee to End Sterilization Abuse, and it was founded to combat coercive sterilization of women of color. And the work that this committee did, it served as a model for federal sterilization reform. It provided really two big provisions, one requiring informed consent in the preferred language for anyone getting sterilized, and sterilization, I mean like getting your tubes tied, and then they also required a 30-day waiting period between the signing and… Signing the consent and actual sterilization.

0:17:04.3 Janelle King: And so I talk a lot about Black women because I’m a Black women and interested in that history, but we aren’t the only group that was affected by what was going on during this time. The Indian Health Service actually sterilized thousands of Native American women during the 1970s, and this contributed to a drop in their average birth rate from 3.7 in the 1970s, to 1.8 in the 1980s. And so we can talk about contraception, particularly in the Black community, and it became really politicized, I would say, in addition to what already happened during the ’70s, in the 1990s. And so during the 1990s, the contraceptive implant Norplant came out. And this was specifically marketed to low income women, especially Black adults and teenage girls. And so after a series of public statements about the benefits of Norplant in reducing pregnancy among this population…

0:18:02.0 Janelle King: And so you gotta think about it, during this time, we have the image of the welfare queen, so unmarried young or young and pregnant women, specifically Black women who are having children using up public services. The politicians or those leaders in charge didn’t want that. And so Norplant became a way to focus on ensuring that women who they deemed socially unacceptable, were not having more children being a bigger strain on the system. So some states eventually introduced unsuccessful bills that would give cash rewards to entice low-income women on public assistance to use the Norplant, and then there were a few states like Tennessee and Washington states that required women receiving various forms of public assistance to get information about Norplant. A few years later, however, we’d know that tens of thousands of women had filed lawsuit against the manufacturer, Wyeth, because they failed to adequately warn about the side effects like irregular menstrual bleeding, nausea, headaches and depression. So this is like a history of contraception as it relates to community of color, in a two-minute spiel.

0:19:12.2 Professor Walden: So it’s important to keep these factors in mind when recommending or discussing contraceptive methods, you have to think about the history and where they come from and how that could impact their choice.

0:19:22.0 Janelle King: This should give you insight about the hesitancy or the distrust of certain methods and why that exists. I also wanted to talk about a group that’s kind of not really represented when we talk about contraception, which is sexual… Women who… Sorry, sexual minority identities, women who identify with sexual minority identities. And so a lot of the information that you get is about heterosexual females, but this group is often overlooked, sexual minorities… Women with sexual minority identities. This specifically is the queer, bi-sexual, lesbian, pansexual women. And they actually have a higher… They’re at a elevated risk for unintended pregnancy, but they are less likely than heterosexual women to receive clinical contraceptive counseling. This group also faces barriers from providers who are unwilling to discuss their reproductive desires. Providers may not have the training in gay, lesbian, bi-sexual health, and then be even more hesitant to provide these women with the contraceptives that they may need. There was a recent survey that found that 80% of gynecologist reported never having received training in transgendered health, and only about a third that felt comfortable providing care to transgendered patients.

0:20:41.9 Janelle King: And so it’s important to provide care and to recognize the group as another group that needs these services and to provide the care that’s inclusive and attentive to their specific needs. And so you’re probably asking, “Okay, why are you telling me all this?” And so the reason why contraceptive methods, contraceptive counseling is important is because the United States has a really high unintended pregnancy rate. And so unintended pregnancy is defined as pregnancy that’s either unwanted, like when a pregnancy occurs, when a patient has no children or doesn’t desire to have any more children, or when a pregnancy is mis-timed in the case where pregnancy happens earlier than desired. And so the latest statistics state that 40%… 48% of all pregnancies in the United States were unintended. And so this rate was greatest among women who were younger, so under the age of 25, lower income, they were also… Had not completed high school. The non-Hispanic, Black or African-American and co-habitating, but never married. And so the pregnancy rate for poor women is more than five times the rate for women who are in the highest income bracket, so that definitely has a financial impact of… Unplanned pregnancy has a financial impact on this group.

0:22:02.9 Janelle King: But unintended pregnancy also is associated with increased risk of problems for both mom and baby. So if she didn’t plan to get pregnant, she may have unhealthy behaviors that she’s engaging in, she may delay getting care, which increases risk for perinatal depression or stress, which then affects the health of the baby and increases the risk for premature birth and a lower birth rate. And so unintended pregnancy is such a big issue here in the United States, that it’s actually included in the healthy people 2030 objectives. Specifically, there are three objectives that we’re aiming to do, and so one is to reduce the proportion of unattended pregnancies, we wanna reduce that rate from 43 to 36.5%. Increase the proportion of women at risk for unintended pregnancy who use effective birth control. And so that’s where you guys play a role, making sure that those patients who need the counseling who need these services are getting it. And so we wanna increase that rate from 60% to over 65%. And finally, we’re looking to increase the proportion of women who get publicly-funded birth control services and support.

0:23:12.0 Janelle King: And so one of the reasons that women are not getting contraceptive counseling, contraceptive services when they often need it, and are looking for it, is because there are missed opportunities from the provider standpoint. And so contraceptive counseling and services are needed for women who often choose to delay or prevent pregnancy, they’re not always offered these services. In clinical settings where they receive the majority of preventative care, so we’re talking the high touch point areas like family medicine, internal medicine, adolescent medicine, they aren’t getting this. In fact, only a small percentage of primary care providers actually administer contraceptive counseling during clinical visits. We also wanna talk about provider bias. And so family planning programs, including contraceptive counseling, are guided by the principle of informed choice with the goal of providing patients with a broad choice of contraceptive methods. And so this choice can often… Is… Can be and often is influenced by the provider opinion and recommendation, which is provider bias. It creeps in, we all have our biases, and this can ultimately play a role.

0:24:31.6 Janelle King: It can lead to limiting the patient’s choice directly or indirectly, when a provider fails to fully assess the patient’s needs and preferences. Provider bias may manifest clinically and influence clinical decision-making that leads to a high number of women with unmet needs for modern contraception. For example, provider bias can lead to counsel patient inequitably based on demographic characteristics. So if we go back to the Norplant example, if you deem somebody unable to take care of their kids because they’re young and they already have a whole… Have two other kids, and now they’re pregnant again, we may force this long-acting method of birth control on that patient because we don’t think that she should have more children. Provider bias can also cause providers to neglect or assess… Or respect the patient’s contraceptive preferences.

0:25:23.8 Janelle King: There was a study from… In 2017 where they spoke to Black and Latina women about their experiences, and it showed that patients felt pressured to accept contraceptive methods despite it not aligning with their reproductive goals, the participants accepted the methods, but quickly discontinued the method, so that’s not really helping anybody. So that’s kind of a… On the screen, you’re gonna see this is actually a quote from one of the participants. So you’re providing is the counseling, you’re giving them a method that doesn’t align with anything they want, they take it out. So what happens? They’re at increased risk for unintended pregnancy. And so these biases contribute to healthcare disparities, excuse me, experienced by racial and ethnic minorities in particular, and definitely has an impact on the patient’s reproductive autonomy.

0:26:13.6 Janelle King: So now I wanna get into specifically patient-centered counseling. And so what it is, it’s rooted in a shared decision-making approach. Patient-centered counseling approach really came out in the early 2000s, and it was a way to address the quality of care that was being delivered in hospitals and long-term care settings, and they’ve just used that and they’ve… You’re providers, and you are nurses who’ve worked in healthcare. So they’ve applied it to a lot of different settings. The institute of medicine introduced this approach, and they noted that to achieve high quality healthcare organizations and care providers need to improve the delivery of patient-centered care. So patient-centeredness highlights that patient’s primary purpose for the visit must be respected, it notes the importance of confidential services and suggest ways to provide them. It encourages the availability of a broad range of contraceptive methods so that the patient can select an option based on their individual needs and preferences, and it reinforces the need to deliver services that are culturally competent in a culturally competent manner that meets the needs of all patients, including adolescents, those with limited English proficiencies, those with disabilities, and those who may identify as LGBTQ.

0:27:39.2 Janelle King: So the overarching belief with contraceptive counseling is that… Patient-centered contraceptive counseling is that the counseling from this standpoint will improve the quality of family planning services and lead to improved reproductive and health outcomes. So this a quick case study, I like to throw these in ’cause I just wanna make sure you guys are listening. So JE is a 20-year-old African-American female, she has one male partner and uses condoms off and on for pregnancy prevention. She’s not looking to become pregnant in the next year, and doesn’t believe in hormonal contraception because she was told that it makes her gain weight. Today she comes in the clinic for a follow-up visits and labs. Oops, no go back a slide. And so… Oh, goodness, did I go back? I’m going forward, hang on. Let’s go back. And so some of the questions that you should be thinking about is, “Is she a good candidate for contraceptive counseling?” So she’s actually coming in for labs and a follow-up visit, she didn’t request contraceptive counseling, she may not be interested.

0:28:50.2 Janelle King: Will she be open to hearing about all forms of contraception because she noted that she’s not really into hormonals. Will she be adherent to the method selected if you were able to convince her to do contraceptive counseling? In her file, you’d recognize that she’s uninsured, and so one of the questions that you may have is, how will she afford her medications. And so these are real life questions that you may encounter as a practitioner, and so the aim is to provide the patient with informations to ensure that they have the best health outcomes. Oops. So this slide, we’re just looking at the different birth control methods available, that improve contraception, and I like this particular layout just because it’s really simple, it highlights effectiveness and then it gives a visual of the rates of pregnancy in terms of if it’s used correctly. So what exactly is contraceptive counseling? Well, I’m kinda gonna go through this with you. There’s actually one, two, three, four, five steps in contraceptive counseling. And so this framework, it actually comes from CDC, and I think it’s very useful in the clinics that I have worked in, this is the model that we used, and of course, we modified it for our specific needs, but this is exactly the steps we would go through when we were counseling young adult females.

0:30:24.9 Janelle King: So the first step is to establish rapport. You guys are nurses or have worked in healthcare, you know how important this is in any visit. And so you wanna use open-ended questions, you wanna ensure privacy and confidentiality. You wanna explain how their personal information will be used, encourage questions. That’s a big one, always. You wanna listen attentively and then demonstrate empathy and acceptance. And so the literature suggests when you counsel and you use a model that emphasizes the quality of interaction between the patient and provider, it’s actually associated with decreased in pregnancy, increased contraceptive use, the increased use of a more effective method and of course, increased knowledge. The next step is obtaining a medical history, and so you guys know how to do this inside and out. But some of the important questions to think about and to include is information about their last menstrual period. When was their last period? How often do they get their period? How long… When they get a period, how long do they bleed for? How much bleeding do they have? And you also wanna look at any other patterns of uterine and vaginal bleeding, because this could impact the choice. If somebody’s a more heavy bleeder, they may want, for example, an IUD, because we know that some of the hormonal IUDs help with bleeding.

0:31:47.1 Janelle King: So that may be an option for them. You wanna talk about recent intercourse, if they’ve had any recent deliveries or miscarriages or terminations. You’re definitely gonna talk about any infectious or chronic health conditions and other characteristics like, is this person postpartum? Is she breastfeeding? Of course, these are gonna affect the patient’s Medical Eligibility Criteria for certain contraceptive methods. And so when you’re taking the medical history, it’s also a good time to create or discuss pregnancy intention or reproductive life plan. This can encourage your patient to clarify any decisions about whether they want kids or when they want kids or how many kids they may want, and also about the timing and the spacing of those children, and this helps to optimize their health before pregnancy to improve birth outcomes when that time comes. You’re gonna discuss previous contraceptive use, learn about what they’ve used in the past, and discuss any successes and challenges that they’ve had with these methods as well, and then you’re gonna note things like smoking status, and you’re gonna note that… Smoking status and allergies. Smoking status is important when talking about some of the hormonal, just because it could be contraindicated in certain groups that I’ll talk about a little later in the presentation.

0:33:03.9 Janelle King: And so you’re gonna talk about contraceptive experiences and preferences, and you’re gonna take your time doing this, you wanna assess a patient’s experience with specific methods, and assess if they have a preferred method in mind. Historically, we know the weight of reproductive injustices that happen to minority women and that can’t be underscored, and it will have an impact on their preferences. Because of that, many African-American women may avoid using hormones as they may be less likely to choose highly effective contraceptive methods like the implant or the IUDs. And it’s not to say that they will… We’re a monolith and that they will never do this, but it will have an impact in terms of whether or not it’s part of the discussion, but it doesn’t mean that you cannot change their mind. And so this slide is a little busy and it’s hard to read, but basically this is the Medical Eligibility Criteria, and so this is one of CDC’s documents. And basically what you’re looking at here, horizontally they list the different contraceptive methods, and then vertically going down the columns, it lists health conditions. And so in each box, when you’re plotting it, it’s gonna have a number from one to four, and let’s say a person has diabetes and they want oral hormonal… Oral birth control pills, and then you’re gonna look that up and find a number in the box.

0:34:29.9 Janelle King: So if there is the number one in the box, it means there’s no restriction with this particular contraceptive method for women with this condition. Number two means there’s evidence that suggests that it’s generally safe for someone to… With this condition to use this particular birth control method. So the benefits, outweigh the risks. And number three, if you are plotting and find a three in the box, it means that theoretically there are more risks associated with this particular method with a specific health condition, and then that patient should choose something else. And if there is a four in the box, it means that it’s completely contraindicated the patient with this condition, let’s say diabetes should not be using, for example, an IUD. Which is not the case, but that’s just an example I’m coming up with. Then you’re gonna take your patient through a sexual history, and again, this is a framework provided by the CDC, and it includes the five Ps. You’re gonna talk about their partners, practices, protection from STIs, their past history of STIs and pregnancy intention.

0:35:38.9 Janelle King: So of course, you wanna make the patient feel as comfortable as possible, some patients are really sensitive about this issue and may not be at ease discussing it, because of experiences with abuse or trauma. The patients may be experiencing currently intimate partner violence, and they may be seeking care for medical concerns, like this may be the only time they’re seeking care for medical concerns. So if that’s the case, be ready to prepare with resources and link them to referrals or needed care.

0:36:10.5 Janelle King: To learn more about the patient’s sexual practice, you wanna ask open-ended questions and focus on the information that you need to help them come to an informed decision. And if no… You should… Even if a patient is not currently sexually active, but they’ve had sex in the past, it’s still important to take a sexual history. And so the CDC’s five P framework, the first question or the first section that you’re gonna go through is partners. So you wanna determine the number of partners they have, determined the gender of partners. It also may be necessary to define what a partner is, because I trust and believe your definition of a partner may not be that… Or that patient’s definition of a partner, so make sure that you clarify that. You also wanna talk about practices, explore the type of sexual activity that they’re engaging in. Is it anal, is it vaginal, is it oral? Protection from STIS. Ask about condom use. Whether or not they use condoms, what situations they use condoms, what situations make it easier or harder to use condoms. Past STI, history of STIs. Talk about their history of STIs, talk about their partner or partners, history of STIS. Explain that the likelihood of STIs are higher with somebody who’s actually had an STI in the past. This may be also a good opportunity to actually go ahead and do an STI screen if it warrants.

0:37:31.3 Janelle King: And pregnancy intention. So do they plan on getting pregnant in the next year? When do they want kids? Do they want kids? It’s important to note that as well. And so this slide, this is the actual… The guide, it’s on CDC, and I think it’s a really good resource, in that it can be modified for your own practices… Practice. And then it also provides sample questions and discussion points to kind of guide the conversation along. And then you’re going to get into a physical assessment and you’re only gonna do that if it warrants it. Most women will need few, or may not need any laboratory tests or exams. CDC can provide you with guidance on the necessary examinations and tests related to the initiation of contraceptions, the chosen contraceptive methods. They can also provide guidance when patients are using a reversible. So let’s say they’re using an IUD or a Nexplanon, if they’re changing from one method to another, they give you guidance in terms of what kind of assessments should be done.

0:38:40.4 Janelle King: And then if a patient is coming in for permanent sterilization, if they’re doing… Getting their tubes tied. CDC notes that this… The assessment should be guided by the clinician who’s actually performing the procedure. And I just noted three points that are kind of important when you’re talking about contraception, one being blood pressure, and specifically, if a patient is starting on an oral birth control pill, it should be taken before initiating the pill. Their evidence… The research says that… Suggest that cardiovascular outcomes are actually worse among women who did not have their blood pressure measured before starting on the birth control pill. Pregnancy test, of course, we’re going to do that, and it’s basically done to assess with reasonable certainty that this patient is not pregnant at the time of starting the birth control. In most cases, a detailed history can also provide that information. And you should know that routine pregnancy testing for every woman is not necessary.

0:39:39.3 Janelle King: You’re also gonna discuss BMI, and so BMI is important because some contraceptive methods may be less of an option for women, so the data suggests that women who weigh more than 90 kilograms, they had an increased failure rate with… When using the patch compared to someone who was below 90 kilogram, so that’s why BMI plays a role. In addition, the data suggests that the Pregnancy Risk was four times higher for obese women who use the emergency contraceptive, the morning after pill, compared to normal weight women. And a final note, it should… You should note that there are certain exams and tests that you don’t need to do to provide contraception to a patient, and so pelvic examinations routinely don’t need to be done unless you’re doing an IUD insertion or fitting for a diaphragm, cervical cytology or other cancer screening, don’t need to be done. HIV Testing routinely does not have to be done, but if you are testing for other STIs, you should go ahead and do an HIV test, CDC recommends that a patient or a person of reproductive age be tested at least one once per lifetime for HIV.

0:40:53.9 Janelle King: Laboratory tests like lipid glucose and liver they… Or hemoglobin, it may not be necessary for all patients, in certain instances, that information may be needed for a particular patient, and so these are the different… I know this slide may be hard to read, but these are the different methods of birth control that a patient can choose from. And when you’re presenting this information, the research and all the people that are smarter than me say that you should use a menu approach. And so what that is is basically what it sounds like, like when you go to a restaurant, they give you a menu, you kinda look through and see what’s good, that’s the kinda same approach that you’ll use with the birth control. And you do that to… In effort to support the patient’s autonomy, and it also places decision-making in the patient’s hands. You wanna give the patient enough information to make an informed decision, but just know it’s not necessary to give them every single detail about every single method. Things you wanna think about when you’re counseling, you’re definitely gonna think about the history of reproductive coercion for minority patients and how that influences the patient choice, patients may and often do… Their choices reflect their personal familial and cultural factors, for example, women will weigh the effectiveness of a method differently.

0:42:16.5 Janelle King: So we’re thinking effectiveness in terms of pregnancy prevention, they may be thinking about effectiveness, like how easy is it to use, well the privacy, what’s the cost, how does that impact about the menstrual cycle? When discussing effectiveness, the American College of Obstetricians and Gynecologists recommend that you talk about contraception, beginning with the most effective method first, so you’re gonna take the very top line on that… On the screen there, and you can talk about those and then you go down from there. And so, in addition to that, they also say that you should use frequencies, so instead of percentages. So you’re gonna say something like 3 out of 100 women will get pregnant versus saying 3% of women. And so you do that because some of the patients may have less understanding about data or percentages and that won’t help them… Inform them about their decisions, or they may not have the proper context or background to make a decision based on the percentage that you’re presenting.

0:43:16.2 Janelle King: You’re gonna talk about how to correctly use the method, they should know how it’s administered or how to use it correctly, and this is maybe important for a patient when they’re choosing a method. For example, if a patient doesn’t like needles, Depo and coming into the office three times a year, may not be the… I’m sorry, every three months, may not be the best fit, it’s all… You can also highlight non contraceptive benefits in addition to preventing pregnancy, things like reducing a heavy menstrual bleeding, noting that with an IUD may be a selling factor for that particular participant.

0:43:52.4 Janelle King: Definitely gonna talk about the side effects and more serious complications, ’cause it can influence a patient’s method about the decision about a method. Talk about the risks and side effects of, under consideration, let them… Help them understand that certain side effects of the contraceptive method may disappear over time. You’re gonna encourage them to weigh the experience with that side effect versus getting pregnant. You’re gonna warn about serious and rare side effects and events such as stroke and DVTs, for example, we know with certain oral birth controls. It’s important to know that individuals who wish to discontinue a method due to perceived or experienced side effects it has… It should, it must be supported by the clinician, even if you don’t think that what their experience is a side effect, or if you don’t think it’s harmful or related to the method. This is also a good time to talk about protections from STIs, including HIV. They should know that unless it’s one of the internal-external condoms, most methods of birth controls don’t protect against HIV. So using a condom in addition to their selected birth central method, can increase protection against HIV. You can also let them know that using a condom provides them with dual protection.

0:45:09.2 Janelle King: So for those individuals who may have multiple partners using a condom in addition to their selected method of birth control, or if they… You have patients, I’ve had patients in the past who are very anxious and wanted the maximum protection, so using… Letting them know that if you use a condom in addition to their selected method, that increases pregnancy prevention and protection. So when you’re educating about the wide range of contraceptive, make sure that, of course, you’re presenting information that’s medically accurate and balanced.

0:45:43.9 Janelle King: The content, format and medium should be that you’re delivering the education, you might wanna use a multi-modal approach, and so we… In the clinics that I’ve worked in, we had papers, we had brochures, we actually had models of the different contraceptive methods so that they could visualize and really have an understanding about what they are selecting. You wanna definitely individualize the information, prioritize the most important information to focus, help the patient focus on their concerns and knowledge gaps, the information should be shared in small digestible tidbits, and you definitely want your patient to ask clarifying questions about the information that’s presented. The teach-back method, which I’m sure you guys are all familiar with, is a great way to help the patient integrate new information and into their existing schema.

0:46:38.9 Janelle King: And so an example of this would be, if a patient selects the birth control pill, you could say something like, “The pill is a new medicine for you. I wanna make sure that you understand what is being presented. Tell me in your own words how you’ll take the pill,” something of that nature. I wanted to take a minute to just talk about emergency contraception since it is a form of birth control and it should be included in your discussion about any forms of contraception. And emergency contraception essentially reduces the chance of pregnancy in the case of unprotected sex, or in the case that a birth control method fails. And so essentially, there are two different kinds, one being the progesterone, only pills there two available that would be Plan B and Ella, these are given in single-dose, just note again, that plan B maybe is less effective in when with higher BMIs or obese women, so you may wanna think about giving Ella. Plan B is a progesterone-only, like I said, and it delays or stops ovulation from happening, it can be taken up to five days after having unprotected sex, but it’s probably… And it is most effective if taken within three days, the plan B or the generic versions of that are available at local pharmacies over the counter, it’s 89% effective in preventing pregnancy.

0:48:00.8 Janelle King: Ella is the second type of progesterone-only pill, and it prevents pregnancy if taken within five days of unprotected sex, it’s only available by prescription, which is kind of a drawback for people who need it in an emergency situation, but it is 94% effective in preventing pregnancy. The copper IUD, which is probably talked about the least, is the most effective method of emergency contraception, it can be placed within five days of unprotected sex, or in the case that birth control fails and it could just be left in place as a form of regular contraception after that. It has to be placed, of course, by a provider, so that is another drawback for patients, but it is 99% effective in terms of preventing pregnancy.

0:48:56.8 Janelle King: So you then wanna discuss potential barriers that the patient might have with the method that they’re thinking about getting, so definitely the social behavior of things, so can the patient… Can they… They wanna talk about their feelings? How is their partner likely to respond, how confident did they feel in terms of using this method correctly and consistently every single day, intimate partner violence and sexual violence, so current and past intimate partner violence and domestic violence can impede the correct and consistent use of contraception.

0:49:30.4 Janelle King: Women may be forced to have sex or practice unprotected sex with male partners, male partners can sabotage their use of family planning. For example, there was a study, 2020 systematic review, meta-analysis by that noted that women who experience intimate partner violence were less likely to use condoms. You should also consider mental health and substance abuse and how that will… Substance abuse behaviors and how that will impact the patient’s ability to use contraception correctly and consistently. So somebody who’s experiencing anxiety or depression, the high levels that may interfere with their motivation or ability to follow through with using that contraception. And then just of note, you should, if this is a barrier or something of great concern, just be ready to have that referral for that patient if needed for both mental health and substance use.

0:50:41.4 Janelle King: You may spend… I worked with young adults. So I spent a lot of times addressing misconceptions, which may be the case for… Depending on the population that you have. And so patients have a negative association with contraception, like the unpleasant side effects or complications, particularly if they’ve experienced this in the past, you wanna ask… Address these questions by asking probing questions to get an understanding of their beliefs, and this gives you the opportunity to share more accurate information, and then so the research says that if you frame the messages… Message positively, it actually has better outcomes in terms of the patient accepting the information.

0:51:22.4 Janelle King: So for example, I’ve had patients in the past that said, “I’ve heard that IUDs cause infertility. I don’t think I should get an IUD because I want kids in the future.” So in a way to address that by addressing the misconception would be to say something like, “Yes, I hear that from my patients a lot, I can see that being a parent one day is important to you, and I don’t… And you don’t want anything to prevent or get in the way of that. With the IUD, your ability to get pregnant, will go back to whatever is normal for you immediately after it’s taken out,” so that’s a good way to get at the misconception and also provide them with accurate information.

0:52:00.5 Janelle King: And then you’re gonna provide the patient with the contraceptive method that they’ve chosen along with the instructions about how to use it consistently and correctly, you’re gonna help them develop a plan for using the method, definitely gonna confirm their understanding and you wanna schedule a follow-up visit. So in the clinical setting that you’re in, you wanna ensure that you have a broad range of FDA-approved contraceptive methods available on site, if you don’t, if there’s something missing, you should have a referral place in a referral system in place to refer the patient who wants a method that’s not available on site.

0:52:38.8 Janelle King: It’s perfectly okay to start the patient on the Quick Start method, which means they’re starting the contraception at the time of the visit rather than waiting for their next period if you are reasonably certain that the patient is not pregnant. And so how do you make sure that they’re not pregnant, if the patient has no symptoms of pregnancy, if it’s been less than or equal to seven days after the start of their normal period, if they haven’t had sexual intercourse, since their last period. If the patient is within four weeks of being postpartum, if she is fully or nearly fully breastfeeding, which means she’s breastfeeding like 85% of the time she hasn’t had a period, she’s less than six months postpartum, these are indicators to the patient is not… You can say with reasonable certainty that the patient is not pregnant and can be started on the given method of birth control.

0:53:31.1 Janelle King: If you’re dispensing things like the pill patch or ring, the more active and involved birth controls, you may wanna think about prescribing for multiple cycles, ideally one year, just to minimize the number of times the patient has to return for follow-up visits on-site. You definitely wanna have condoms available on site, make them readily accessible for your patients. If the patient has chosen a method that’s not available on-site or at the same day, you may wanna think about giving them another method to kinda bridge them over until they’re able to be seen and start their preferred method of birth control. And of course, lastly, after you do this, you wanna document this in the chart, because we all know as nurses if it’s not documented, it’s not done. With regards to ongoing monitoring adherence, you wanna develop a plan for follow-up, and you definitely wanna consider the patient’s risk for discontinuation, follow-up visits gives you the opportunity to inquire about any initial difficulties that patient may have experienced. And follow up-visits allow you to assess any changes in the patient’s medical history, like changes in risk factors or medications that might affect the safeties of their selected birth control method.

0:54:46.0 Janelle King: You may wanna consider alternate forms of a follow-up visits like telephone or virtual, if at all possible. If your patient is using the method consistently and correctly, if you don’t have any concerns, you wanna create a long-term plan and then you wanna dispense additional medications if you haven’t done so at the beginning. If the patient is having issues, this is a good time to ask patients if they’d be interested in selecting a different method, and you may wanna engage in another round of contraceptive counseling with that patient. Safety and efficacy is a really big deal, and especially when I was working with young adults, this is kind of another area that we always discussed and they wanted to talk about. And so during the counseling session, you address these, the safety and efficacy of the methods, you wanna talk about effectiveness in a way that’s informative, but more importantly, something… Talk about it in a way that’s meaningful to your patient. By doing that, I think it’s important to talk about… It’s important to talk about or to distinguish between perfect use and typical use. So when… You see in the literature that says something about with perfect use, it’s X%, 30% of women will get pregnant, what that means is that when with the chosen method, if it’s used consistently and correctly, every single time.

0:56:08.2 Janelle King: Like for example, taking the birth control pill, you take it correctly around the same time of day, no later than… Outside the 12 month or 12-hour window, this is the percentage of women that will become pregnant. I think it’s more common with for providers to give patients information about typical use. So this is how the average patient or person will take that medicine. We’re not perfect beings, so we may not use it consistently and correctly, every single time, like for example, putting on a condom, if you’re using a condom as your preferred birth control and then it breaks during intercourse, so it wouldn’t be perfect use. When talking about effectiveness. It’s important to present information that’s really relevant to this decision-making for the patient, and that may… That’s actually more important than perhaps the completeness in terms of talking about complete information or providing a patient with complete information. So a quick case study. This is LW. And so LW is a 30-year-old Black female. She’s a mom of a three-year-old daughter, has been in a long-term relationship with her partner of five years, she has recently been started on the hormonal birth control patch. So while conducting a medical history, she discloses that her depressive symptoms have become worse recently, and she hasn’t been feeling like herself, and so she explains that she’s recently been let go from her job and has been feeling the financial strain.

0:57:44.0 Janelle King: Her daughter’s child care provider has also recently decided to close her home-based center, and today she’s come into the clinic for a follow-up contraceptive visit, and she notes that so far the patch is working fine, but sometimes I forget to take it off and then put a new patch on. So a couple of questions to consider for her, Is the hormonal Patch still the best contraceptive method? Will she be open to discussing other methods? She’s uninsured, and are there any low-cost contraceptive methods or payment assistant programs available for her? Should I conduct a mental health screening on her? The symptoms that she feeling, is that a result of the birth control or is that just because of her life circumstances? And then, what referrals, does she need a referral, and what are some of the important factors to consider when making those referrals.

0:58:42.0 Janelle King: I did wanna address some of the perceived barriers to contraceptive counseling, ’cause I recognize it’s healthcare, we don’t work in a perfect system, so there are gonna be barriers. And so there was a study that came out in 2010 by Aires and company, and so they specifically were asking primary care providers, what are some of the barriers that you experience when trying to do contraceptive counseling? And so one of the things that came up was the lack of knowledge, and so these providers, the respondents, they were very familiar with the condoms and oral contraceptive pills, and that’s what they prescribed most often, but they lack knowledge about other methods of contraceptive methods, and then they also noted that they didn’t think they had enough training.

0:59:29.3 Janelle King: And so the main challenge that they reported was just keeping abreast of new contraceptive methods that were coming out. The lack of training, which I just mentioned in the comfort with contraceptive counseling, and so they thought that they needed to improve their skills to initiate certain methods like an IUD, putting an IUD or putting in the arm implant. Assumptions about patient risk was another… Patient pregnancy risk was another big thing. So one of the example cited was older women of reproductive age who had previously had children were seemed to be responsible enough not to get pregnant. And so we know that’s not the case. One of the big things that came out of this particular study was the use of informal risk classification scheme, so thinking it kinda goes hand-in-hand with what I just said, these patients know how to prevent pregnancy, these ones don’t. And so one of the specific examples they noted was women who reported not currently using… Being sexually active were thought not to need contraceptive counseling despite the reality that we know that they could initiate sexual activity before their next clinical visits. They also had negative beliefs about contraceptive methods.

1:00:38.1 Janelle King: And so, particularly, they had inaccurate beliefs about these methods, and it definitely influenced how they were providing the contraceptive counseling, they described a number of beliefs about the appropriateness of contraceptive options for certain patients as influencing the contents of their discussions. One respondent said, we discourage the patch use because of the excessive amount of hormones that the students don’t need. And finally, they talked about the reliance on other providers to start, to initiate discussion about contraceptives. One provider… Or they noted that sub-specialists often initiate medications that affect women’s fertility, but they don’t provide the counseling, other providers noted that in the study refused to start a… Refused to give contraceptive counseling to women being treated for medical conditions believing that it was the responsibility of the sub-specialist, so this is healthcare, we treat individual pieces instead of looking at the entire person.

1:01:46.7 Janelle King: I also wanted to highlight some of the system level barriers that may make contraceptive counseling a little harder. One thing of note is that when I was looking at the research, there was a lot of frustration in trying to navigate ordering contraceptive specifically looking at the long-acting reversible like the IUDs and the Nexplanon, the arm implant. So respondents noted that there was frustrations trying to just order from the insurance companies, there’s a lot of time and work to just set that up, obtain approvals, order the device, and setting up a secondary appointment. Navigating the coverage details for anybody’s insurance is also always a big frustration.

1:02:28.9 Janelle King: It’s not always straight forward for the clinic or the patient, and so there’s variations on how the coverage is administered, and that can definitely impact the service or the type of type of method that the patient receives. There were also barriers to just accessing things like the emergency contraception. There was a study specifically of pharmacists, and they found that 40% of pharmacists incorrectly reported an age restriction for purchasing Plan B, so they believe that Plan B could only be purchased by people who were 17 or 18 years old, when we know in fact that it is available to anyone of any age. So these structural and policy restrictions, they need to be modified and changed in ways that promote health equity to ultimately improve patient care and outcomes.

1:03:23.9 Janelle King: So let’s take a look at patient coverage for contraceptive counseling because cost matters to women when they’re choosing a method. I looked at federally, what does it look like? And we know that the Affordable Care Act was enacted in around 2010, and it requires the coverage for 18 methods of contraception by women, including female sterilization or getting tubes tied and this was required along with related counseling and services.

1:03:50.5 Janelle King: It also requires that the coverage be provided without any cost sharing to the patient, so there shouldn’t be any out-of-pocket payments, copayments or deductibles, and this guarantee applies to most private health plans nationwide. I also took a look at some of the state coverage, so Medicaid coverage. Some states have amended or expanded their Medicaid requirement to match the federal laws requiring coverage for the full range of contraceptive methods, and they’ve eliminated out-of-pocket cost for patients and other limiting health plan restrictions. And then there are states who have gone beyond the federal guarantee requiring coverage for contraceptive methods that are available over the counter without a prescription. Payment for services was something else I took a look at and that you guys should be aware of. We’re in healthcare although we do it, altruistically because we’re nurses, it is still a business, and so a lot of times, I looked at the research out there. And so from a provider perspective, you may encounter challenges when seeking payment for contraceptive and specifically looking at the long-acting reversible so those are the implants and the IUDs in both fee-for-service and managed care environments, there may be some barriers when trying to implement that in inpatient and outpatient settings.

1:05:19.2 Janelle King: So for example, in inpatient settings, most payers, including Medicaid, pay for labor delivery admission services through a global obstetric fee or based on a DGR code, and that may not sufficiently address the additional costs associated with the provision of LARC devices immediately after delivery. So they’re paying for the delivery of the baby, but it’s not paying for the putting in the actual device like a Nexplanon can be inserted right after delivery.

1:05:50.5 Janelle King: Many states don’t provide additional payments for the cost of LARCs and do not provide additional payments for either the hospital or the practitioner for the placement of LARCs on the state level. In outpatient settings, the payment rates for the LARCs or the long-acting reversible devices may be insufficient for the placement of those devices. LARC placements may require a significant upfront cost for the provider, primarily the cost to obtain the device prior to placement, and this is not certain for every state, but every state is a little bit different. And even when devices are covered through the patient’s pharmacy benefits, in the absence of prior arrangements or state policies, providers may not be able to return a dispensed device if it’s not used by the specific patient who it’s dispensed for and then these devices must then be discarded at a financial loss to the provider. May also run into issues if the state limits payment on the initial LARC placement, but do not provide payments for replacement and reinsertion when necessary, so that provides another disincentive.

1:06:56.9 Janelle King: So what that means is, let’s say a patient comes in for an IUD and you place that IUD, but three days later, the IUD comes out, which can happen in certain cases, you will be paid for the initial placement, but if the patient comes in for that second IUD, you may not receive any payment for that. Additionally, some states and managed care organizations that require prior authorization as part of… Part of their prior authorization may question the medical necessity, absent the failure of using another birth control method, sometimes called Step Therapy. So they may ask you, why is this patient getting an IUD when they haven’t tried anything else, like the birth control pill or the Depo. Here in Georgia, where I live under the Medicaid, Georgia’s Medicaid new policy for practitioners who provide LARCs or the long-acting reversible in free-standing outpatient FQHCs or the rural healthcare settings can bill for these long-acting reversible devices, but they are reimbursed for the insertion and removal through a prospective payment system. So it’s an all-inclusive rate in which Medicaid payment is made based on the national rate, and it’s adjusted based on the location of where the services are done.

1:08:09.0 Janelle King: So that means that you could be making a profit or you may not be depending on where you are. I just wanted to point out, specifically for patients, even though we have the expansion of the ACA, cost of contraception is still a barrier for some patients. And so the ACA says that we are supposed to… Patients, people are supposed to be able to receive any contraceptive, all the 18 different ones, and the services and the counseling associated with that. But we know that in administering coverage, different plans may use formularies, prior authorization requirements and similar restrictions that could affect the patients choice of what method they could receive.

1:09:00.3 Janelle King: And studies have shown that even with a seemingly small co-payment, and other sharing… Other cost sharing requirements, this dramatically reduces the preventive healthcare use and that’s particularly among low American… Low-income Americans. So the take home message, just a couple of things to highlight, you definitely wanna use a shared decision-making approach when talking about contraceptives, it definitely engages the patient and puts the decision-making back into their hands. You wanna provide the patient with meaningful information and this information should be individualized to that patient, depending on the method that they’re using or they would like to select. You’re gonna use your active listening skills, which I’m sure you’re used to doing as nurses and providers of healthcare, recognize your biases, these exist, and we’re all sort of guilty. We should recognize them and limit them so they don’t impact a patient’s choice.

1:10:03.7 Janelle King: You wanna identify a structural and policy… I’m sorry, barriers, and just help the patient overcome these barriers so that they can get what they need. You wanna help the patient select the contraceptive method that best fits their lifestyle, we know that that will… Having a method that best fits their lifestyle, equals greater success, equals greater adherence means no less chance of unintended pregnancy, and of course, we’re gonna lead with empathy. And so when we do all that and put that all together, this leads to reproductive autonomy for these patients and more sexual liberty, and which ultimately will lead to improved patient outcomes and patient care. So that is it for me. This is my contact information. I thank you again for allowing me to share one of the areas of my passion, and I know that you guys will go forward and do great things.

1:11:07.3 Professor Walden: Thank you so much. This was great because this was more of… We always get the technical side as providers and it’s why you should choose this and what is going on with this patient, but this was definitely more on the educational side as to why we should be thinking the way that we should be thinking, or not thinking, or like I say, turning down our inner radio on those biases and addressing our patients. So this gave a lot of good tools and techniques in order to do that, so I really appreciate that.

1:11:42.6 Janelle King: Thank you.

1:11:42.7 Professor Walden: One of the things that I wanted to… What I didn’t know, and you said it early on in the presentation, it was, I did not realize that unintended pregnancy was included in the 2030 Healthy People.

1:11:57.4 Janelle King: Yeah.

1:12:00.0 Professor Walden: I don’t know how I feel about it. You said it, I just kept thinking about it going, “Huh.”

1:12:07.0 Janelle King: Yeah, there’s just… I guess I… Even though I know looking at the research, it’s still a huge deal here in the United States, and we are a nation of so many resources. We should be doing better.

1:12:22.8 Professor Walden: We should, we should. I definitely have thoughts about it, but to have them include it was definitely like, Wow, we’re really looking at this because, obviously when things are included in these reports, it’s a… And that means also there’s money that will be driven…

1:12:43.6 Janelle King: Correct, hopefully.

1:12:44.9 Professor Walden: Yeah, hopefully to that.

1:12:47.7 Janelle King: Yeah, I think we just… It’s such a small thing, I guess, when you’re looking at the scope of issues that patients may have, but I think it really can impact their overall health and well-being, and so why not address it?

1:13:01.8 Professor Walden: Yeah, I know, that’s good. And then I’m glad you mentioned this, I was wondering if you were… ‘Cause I had it in my notes, but Plan B and Ella, mentioning both of those because I think everyone knows Plan B, but I honestly, I’m not even sure providers are aware that Ella is out there, unless they’ve had to give it before.

1:13:24.2 Janelle King: Right, and that is the case. I think I was just very fortunate to work in clinics where we had both available, and then I’m very fortunate, I work with great providers, female providers who kind of educated me like, “This is why we would give Plan B versus… ” Or, “This is why we give Ella versus giving Plan B.” So just recognize that there are differences. Who knew that a person of a certain BMI is less… They should be less likely to get Plan B and we should really actually be prescribing Ella. So just getting that information out there so that providers know, you guys will know that, “Hey, this person is a little bit bigger, this may not work for them.”

1:14:01.3 Professor Walden: Right. Right. And the way… And just so if anyone… Excuse me, if any nurse practitioner is watching, the way that you can get around your patient having it when they need it is just writing them a prescription, and just let them keep it on hand so that way if something happens, they don’t have to call you. It’s a fight, ’cause you know how sometimes it can be a struggle. I’m mistaken.

1:14:27.7 Janelle King: Yes. Most definitely, we did that on occasion, we would just have it as just one of the standing orders for that particular patient so that… Okay. Here you go. No questions asked. You need it, we’re gonna give it.

1:14:43.1 Professor Walden: Absolutely, no, but this is great and full of good useful information and things that we need to be discussing as providers and aware of, because I know a lot of us, especially the newer ones, will go and we work in the lower income, lower socio-economic areas. And so this is our population, and their population…

1:15:05.4 Janelle King: And they need it. It’s a blessing that I was able… I was in these urban centers working with these young girls, they taught me a lot, but they need this and they actually wanted as much as they may put up these barriers, but they want the information. And we had great success. Patients, sometimes I felt like, “Why? You don’t need to be here this week but why are you… ” They just liked coming in, the rapport was good, they trusted us, and so we were able to provide them with quality care and give them resources and tools to just not only improve their reproductive and sexual health, but just their lives. So it was a great experience.

1:15:43.6 Professor Walden: No, this is great, I appreciate it so much. And for all of you that are out there listening, I hope that you enjoyed it as well. Ms. King has given us some great tools that we are going to upload in for you, into the portal, so that you’ll have access to those as well. And some of the other things that you’ve mentioned, the CDC charts and things like that have already been uploaded into the portal, so that you guys have access to those and you can print them out and use them at your leisure in your practice. So again, thank you so much for joining us. And guys, as always, I will see you guys on the next go around, talk to you soon bye.

1:16:28.2 Professor Walden: Awesome, thank you so much. No, it was very, very good listening and talking. Because we’ve done contraceptive talks, but again, since we’re providers, it was more technical, use this for this, choose this for this, and this is more of why our patients are probably reacting to us, that they’re reacting. And I have a lot of other, who don’t look like me, providers. So this is good information for them as well, it’s always, always educating.

1:17:05.2 Janelle King: Absolutely. Excellent, thank you. Thank you again, you guys. Your team was great. You made it very easy. Hopefully, you’ve got my little handout, I had sent it.

1:17:17.3 Professor Walden: Yes. Yes.

1:17:17.9 Janelle King: So hopefully you have that. If you need anything else, if I’ve forgotten anything, please reach out. It’s been a very good experience, I appreciate it. Thank you.

1:17:27.5 Professor Walden: Oh, thank you. So we’ll upload everything, and we’ll also upload all your handles so that they can follow you and track you down on all social media channels and… Yeah, no, I will… Absolutely reach out. If you need anything from me. Or if you ever need anything there and I will definitely reach out if I need anything else.

1:17:47.2 Janelle King: Thank you. Thank you.

1:17:48.1 Professor Walden: I can give you something, I’ll be like, “I know someone. I know someone.”

1:17:53.6 Janelle King: I appreciate it. It was like… I was like, “Oh, let me get to work these people are real so let me get my stuff together, can’t just come in willy-nilly, it’s… “

1:18:04.5 Professor Walden: I love it. It really was great. It really was great. I appreciate it.

1:18:08.8 Janelle King: Thank you. You have a good rest of your day. Again, if your team needs something from me, just please… Or I’ve forgotten something, let me know.

1:18:17.9 Professor Walden: Alright, thanks Janelle, you too. You have a good one.

1:18:20.2 Janelle King: Thank you.

1:18:21.6 Professor Walden: Bye.

1:18:22.3 Janelle King: Bye-bye.

Janelle King, MPH, BSN, RN, is a registered nurse with a Master’s degree in Public Health. Her clinical background includes clinical research, HIV outreach, adolescent medicine, and college health. During her nursing career, she has spent many years educating young adults about reproductive and sexual health.

Janelle’s love for patient educations inspired her to create and use social media platforms to educate her predominantly African American female fan base about their vaginas (anatomy and hygiene), periods, and sex. She also teaches about hormonal and non-hormonal birth control options and sexually transmitted infections. She aims to normalize taboo topics and dispel myths and misconceptions related to sexual health. Janelle believes her relatable demeanor; clinical and personal experiences help women better understand their bodies and choices.

An accomplished blogger and writer, she has contributed to Women’s Day Magazine, AARP Sisters Newsletter, and The Body: The HIV/AIDS Resource, among many others. She is a Journey Award winner and has been featured on several podcasts, including Zuri Hall’s Hot Happy Mess, Femme Focus Podcast, and Be Well Sis. In her spare time, you can find her writing about reproductive health and wellness on her blog thenursenote.com

all social media handles @thenursenote