Introduction to Reproductive Life Planning and Motivational Interviewing

Meghan Benson, MPH, CHESDirector of Community Education

[email protected]

Anne Brosowsky-RothCommunity Education Resource

[email protected]

414-289-3767

Reproductive Life Planning & Motivational Interviewing

Safe Healthy Strong 2014Pre-Conference InstituteAugust 6, 2014

UW-Milwaukee Zilber School of Public Health

mailto:[email protected]

mailto:[email protected]

AboutPLANNED PARENTHOOD

Copyright © 2013 Planned Parenthood of Wisconsin, Inc.

Annual reproductive health exams Birth control (including EC & condoms) Cancer screening Colposcopy STI testing & treatment HIV testing & risk-reduction education Pregnancy testing & all-options education Abortion care Referrals for other health & social services

Copyright © 2013. Planned Parenthood of Wisconsin, Inc.

Conflict of InterestStatement

Meghan Benson• I have received no support or commercial

funding for this presentation, or for any products mentioned herein.

Anne Brosowsky-Roth• I have received no support or commercial

funding for this presentation, or for any products mentioned herein.


Agenda

9 – 9:30 a.m. Welcome & Introductions9: 30 – 10:30 a.m. What is Reproductive Life

Planning10:30 – 10:45 a.m. BREAK10:45 – 12:15 p.m. Contraceptive Efficacy12:15 – 1:15 p.m. LUNCH1:15 – 3:15 p.m. Motivational Interviewing3:15 - 3:30 p.m. BREAK3:30 – 4:30 p.m. Case Studies & Role Play4:30 – 5:30 PMQuestions | Comments | Wrap up

Objectives

List the core components of a reproductive life plan.

Define the terms “perfect use” and “typical use” in relation to contraception & explain how this fits into the WHO “Tiers of Contraceptive Efficacy” framework.

Examine why Motivational Interviewing (MI) is an effective tool for fostering behavior change.

Express the main features of an MI approach to counseling.

Demonstrate how to develop a Reproductive Life Plan with a patient or client using MI tools.


2006 CDC Guidelines for Interconception Care

Goal: to improve the chances that an infant will be born healthy by addressing any issues prior to conception

Increase KNOWLEGE, attitudes and behaviors of men and women before conception takes place

Increase ACCESS to health services Improve INTERVENTIONS after an adverse

pregnancy outcome Reduce DISPARITIES in adverse pregnancy

outcomesCopyright © 2013. Planned Parenthood of Wisconsin, Inc.

Unintended pregnancy in the US


Source: the Contraceptive Choice Project

http://www.youtube.com/watch?v=cd46pXtMHOo

Title X FY 2014 Program Priorities

US Department of Health and Human Services: Office of Population Affairs

1. Assuring the delivery of quality family planning and related preventive health services…

2. Providing access to a broad range of acceptable and effective family planning methods and related preventive health services…

3. Assessing clients’ reproductive life plan as part of determining the need for family planning services, and providing preconception services as appropriate

4. Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations…

5. Identifying specific strategies for adapting delivery of family planning and reproductive health services to a changing health care environment…


Links between childbearing and poverty

Lower educational attainment in women

Reduced future earning potential

Singe-parent families more likely to live in poverty

Increased healthcare costs



Does intent matter?

Source: Child Trends Institute. The Consequences of Unintended Childbearing,

White Paper. (2007)

Women experiencing unintended pregnancy tend to: Delay prenatal care Be at greater risk of physical

abuse while pregnant Have higher rates of negative

health outcomes during and after pregnancy.

Children who result from unintended pregnancy may: Have poorer physical and mental health outcomes


Pregnancy and “intendedness”

Source: Alan Guttmacher Institute. Facts in Brief: Facts on Unintended Pregnancy in the United States (January 2012).

Pregnancies by In-tention Status

Intended

Mistimed

Un-wanted

Unintended pregnancies account for about 49%* of all pregnancies. They include pregnancies that were:• Mistimed 29%• Unwanted 19%

*these numbers do not add up to 100% due to rounding.

Nearly 50% of unintended pregnancies occurred in a month that couples used a method of contraception.


The RLP assessment…

Patient centered Empowering for the participant Includes key basic questions that

allow the client to elaborate Invites goal setting and action

steps (Motivational Interviewing)

SHORT!

Source: Deliberations of the Ad Hoc Committee of PCCHC Select Panel on Reproductive Life Planning, Washington, DC, November 23, 2009.



Reproductive Life Planning - RLP


RLP is client-based assessment of their own goals to determine where childbearing fits into

Education Work/Career (Any?) Future Children

When? How many? How often?

So they can create a plan to meet those goals.

RLP at the Most Basic

1. Do you want to have a (another) baby?

2. Are you having sex and is there a chance you could get pregnant or get someone pregnant?

3. If you don’t want a baby right now, what are you doing (or planning to do) to keep from getting pregnant or getting someone pregnant?



BIRTH CONTROL:WHAT DO YOU KNOW?



Less than 1 per 100 Implant IUDs

Female sterilization

Male Sterilization

2 – 9 per 100 LAM

Breastfeeding Depo Shot The Pill The Patch Nuva Ring

15-24 per 100

DiaphragmExternal condom

Internal condom Withdrawal Cervical cap

About 25 per

100 Emergency Contraception

Fertility Awareness Spermicides The sponge

Less effectiveAbout 25 pregnancies per 100women each year

More effectiveLess than 1 pregnancy per 100women each year

COMPARING BIRTH CONTROL EFFECTIVENESS

Source: Adapted from WHO, 2007 and ARHP Method Match.

Health Behavior Change


Health Behavior

Health behaviors are impacted by many, intersecting and overlapping variables

Mutable and immutable factors

Factors related to individual, family, community, environment, culture, society, and various institutions (i.e. schools, health care, legal system, etc…)



Consider the Context of Health Behavior


Health Behavior Change

Health behaviors are complex with factors at many levels contributing to both behavior intention and ultimately behavior

Causation and even correlation can be challenging to demonstrate between various factors and health behaviors

This makes health behavior change hard – for everyone!



Health Behavior Theory

Unified Theory of Behavior Jaccard, J. and Levitz, N. (2013). Parent-based

interventions to reduce adolescent problem behaviors: New directions for self-regulation approaches In G. Oettingen and P. Gollwitzer (Eds.) Self-regulation in adolescence. New York: Cambridge University Press.

Jaccard, J. and Levitz, N. (2013). Counseling adolescents about contraception: toward the development of an evidence-based protocol for contraceptive counselors. Journal of Adolescent Health, 52, S6-S13.

Transtheoretical Model of Behavior Change or “Stages of Change” Model



Unified Theory of Behavior

Determinants of Behavior Intention



Unified Theory of Behavior

Moderators of Intention-Behavior Relationship



Transtheoretical Model of Behavior Change


Questions?


1. Get into pairs. One person is the counselor, the other the client.

2. Counselors: You ONLY have 2 minutes to explain to your clients why they should use birth control.

3. Clients: Listen carefully to your counselors.

Role-play 1


Motivational Interviewing (MI)

MOTIVATIONAL INTERVIEWING is a quick, effective, and client-centered technique that allows clients to define their own goals and make their own choices by helping them identify what is personally meaningful in their own lives.


A set of skills you can use to help your clients motivate themselves for success.

MI + RLP


More Information on Motivational Interviewing


Today, we will focus on utilizing MI skills in the context of Reproductive Life Planning

For further MI resources & training – Motivational Interviewing Network of Trainers:http://www.motivationalinterviewing.org/motivational-interviewing-resources Professional Certificate in MI:http://continuingstudies.wisc.edu/certificates/motivational-interviewing

http://www.motivationalinterviewing.org/motivational-interviewing-resources




http://continuingstudies.wisc.edu/certificates/motivational-interviewing




What is Motivational Interviewing (MI)?

A collaborative, goal-oriented method of COMMUNICATION

Strengthens an individual’s motivation and movement toward a goal by

exploring the THEIR OWN arguments for change


Benefits of MI for Providers

Reduces frustration with our clients (and with ourselves).

Removes our own ego from the education or counseling process.

Releases us from responsibility if a client doesn’t follow through.


Benefits of MI for Clients


http://motivationalinterviewing.org/

Guiding Principles of MI

Resist the righting reflex

Understand your client’s motivations

Listen to your client

Empower your client


Behavioral Characteristics of MI

Understand from the CLIENT’S frame of reference

Express ACCEPTANCE and AFFIRMATION

Elicit and SELECTIVELY REINFORCE the CLIENT’S: Own motivations Problems and concerns Change talk (desire, ability, reasons, need to

change)


The Spirit of MI

RESPECTFUL

OPTIMISTIC

EMPATHETIC

COLLABORATIVE


Another way of stating the principles of MI –

Roll with resistance – don’t argue

Express empathy – use reflective listening

Develop discrepancy – elicit change talk

Support self-efficacy – it’s ultimately the client’s responsibility


Behavioral Characteristicsof MI

INCREASE client’s COMMITMENT to change

E-P-E: Elicit – Provide – Elicit ELICIT client’s ideas and needs PROVIDE information and advice

Ask permission, unless client asked for advice

ELICIT client’s reactions and commitment to change


1. Divide into the same pairs you were in for the previous activity.

2. Stay in the same role.3. Client: You have 2 minutes to explain to

the counselor all the reasons that you think you should use birth control.

4. Counselor: Listen carefully to your clients.

Role Play 2


Expect – and accept – Ambivalence


On one hand, I want to be successful.

On the other hand,

all kinds of things stand in the way of

making that happen.

REWARDS

OBSTACLES

It doesn’t mean the client doesn’t care…

REWARDS

OBSTACLES


If I’m careful about using birth control:• I won’t get pregnant [get

someone pregnant] until I want to.

.

But..• There’s too many side effects.• It’s too expensive. • I can’t get to the clinic.• My partner doesn’t want me to

use it. • I’m not having sex right now

anyway.

Ready, Willing, Able

Individuals won’t even attempt to change their behavior if it seems impossible.

Use a scale to gauge readiness, willingness, or ability to change.

Confidence Ruler

Least Most


12

34

56

78

910

On one hand…


Client: A “3.”Facilitator: Why not a “1” or a “2”?Client: I know I’m not ready for a baby, and I don’t know if my boyfriend would be a great father. I guess having a baby

wouldn’t be the worst thing in the world, and we would have to figure it out. Facilitator: Why do you think this number isn’t

higher?Client: I want to be sure I’m ready first.

Example


https://www.youtube.com/watch?v=5ePJw0NjEec

Don’t jump ahead!

Affirm the individual’s freedom of choice and self-direction.

Monitor for readiness.

Don’t push for a commitment when the individual isn’t ready for it.


The Flow ofChange Talk


Intervention (MI)

Client assess

es their own

GOALS

Client commit

s to work on

goals and

makes a PLAN

CLIENT ACHIEVES GOALS or MODIFIES BEHAVIOR

S

RecognizingChange Talk

D = Desire for Change – “I want to…”

A = Ability to Change – “I could…”

R = Reasons for Change – “I would…if…”

N = Need for Change – “I have to…”

A = Activation – Person is ready, willing or preparing.

C = Commitment to Change – “I’m going to…”/“I will…”

T = Taking Steps – “I’ve started to…”/“I am…”


• Open-ended questions• Affirmations• Reflections• Summaries

Eliciting Information With OARS


Open-Ended Questions/ Statements

Require more than a one word (yes or no) answer.

Elicit more of a person’s thoughts and feelings about a behavior.


Close-ended questions

Open-Ended Questions

How many children do you plan to have?

What are your thoughts about having children in the future?

Do you use birth control? How do you feel about using birth control?

Do you talk with your partner about preventing pregnancy?

Tell me how you and your partner talk about preventing pregnancy.

Affirmations

Emphasize strengths. Nurture competency. Focus on

descriptions. Be genuine!


What affirmations can you offer a client who’s been diagnosed

with an STI?

Reflective Listening

Reflections don’t have to be perfect (they can even be wrong!)

Feeling understood can make a client more open to considering change.

YOU choose what to reflect to the client!


Reflective statements lead to better understanding.

Types of Reflections

A. SIMPLE Repeat Rephrase

B. COMPLEX Double-sided (AND not BUT) Paraphrase Metaphor Continue the thought

C. AMPLIFIED Exaggerate Understate


Summaries

Collect the material that has been offered.

Link something that was just said with something that was said earlier.

Transition to the next topic.


Rolling with Resistance


Use amplified reflections Shift the focus Reframe Agreement – with a twist Stress personal choice Side with the negative

Thoughts, ideas, questions?


What resources would you need to implement a discussion of RLP with your clients?

Are you ready?


Resources

(CDC) Reproductive Life Plan Tool for Health Professionals http://www.cdc.gov/preconception/documents/RLPHealthProviders.pdf

(CDC) Reproductive Life Plan Worksheet for Patients

http://www.cdc.gov/preconception/documents/ReproductiveLifePlan-Worksheet.pdf

(WI DHS) BadgerCare Family Planning Only Serviceswww.dhs.wisconsin.gov/badgercareplus/fpw.htm(information available in English/Spanish/Hmong)


http://www.cdc.gov/preconception/documents/RLP

http://www.cdc.gov/preconception/documents/



http://www.dhs.wisconsin.gov/badgercareplus/fpw.htm

Resources

Planned Parenthood of Wisconsin, Inc. (locate health centers, online information about sexual and reproductive health) www.ppwi.org

Bedsider.org (contraceptive info, personalized method comparison tool, appointment/birth control reminders)

ARHP (Association of Reproductive Health

Professionals) My Method Match Patient Tool arhp.org/methodmatch


Selected References


Alan Guttmacher Institute: Facts on Unintended Pregnancy in the United States (January 2012) guttmacher.org/pubs/FB-Unintended-Pregnancy-US.pdf

Child Trends Institute. The Consequences of Unintended Childbearing, White Paper. (2007) www.childtrends.org/Files//Child_Trends-2007_05_01_FR_Consequences.pdf

The Choice Project. choiceproject.wustl.edu

The World Bank. “Poverty Reduction. Does Family Planning Matter?” (2005) siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/GreenePovertyReductionFinal.pdf

(CDC) Recommendations to Improve Preconception Health and Health Care in the United States (2006) www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

http://www.childtrends.org/Files/Child_Trends-2007_05_01_FR_Consequences.pdf



Selected References


Frey KA, Navarro SM, Kotelchuck M, Lu MC. (2008) The clinical content of preconception care: preconception care for men. American J Obstet Gynecol. 2008 Dec;199(6 Suppl 2):S389-95

Frost JL and Linberg L (2012) “Reasons for Using Contraception: Perspectives of US Women Seeking Care at Specialized Family Planning Clinics.” Contraception. Epub ahead of print, 27 September 2012.

Sanders L. (2009) “Reproductive Life Plans: Initiating the Dialogue With Women.” MCN: Journal of Maternal and Child Nursing. 36(4)342-347.

Introduction to Reproductive Life Planning and Motivational Interviewing

Healthcare

Transcript of Introduction to Reproductive Life Planning and Motivational Interviewing