Anne Brosowsky-RothTraining SpecialistPlanned Parenthood of Wisconsin, Inc.

Anne.Brosowsky@ppwi.org

Meghan Benson, MPH, CHESDirector of Community Education

Planned Parenthood of Wisconsin, Inc.Meghan Benson@ppwi.org

Reproductive Life Planning and Motivational Interviewing Thursday, June 4, 2015

THE UNIVERSITY OF WISCONSIN - MILWAUKEE JOSEPH J. ZILBER SCHOOL OF PUBLIC HEALTH

• Annual reproductive health exams• Birth control (including EC and

condoms)• Cancer screening• Colposcopy• STI testing and treatment• HIV testing and risk-reduction education• Pregnancy testing and all-options

education• Abortion care• Referrals for other health and social

services

About Planned Parenthood

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.

Conflict of Interest Statement

9 – 9:30 a.m. Welcome and 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 and Role Play4:30 – 5:30 p.m. Questions, Comments

Wrap up

Agenda

• List the core components of a reproductive life plan.

• Define the terms “perfect use” and “typical use” in relation to contraception and 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.

Objectives

Source: the Contraceptive Choice Project

Unintended Pregnancy in the

United States

• Lower educational attainment in women

• Reduced future earning potential• Single-parent families more likely to

live in poverty• Increased healthcare costs

Links Between Childbearing and

Poverty

Intended Mistimed Unwanted

Unintended pregnancies account for about 49%* of all pregnancies. They include pregnancies that were:

• Mistimed 31%• Unwanted 20%*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.

Pregnancy and “Intendedness”

Source: Alan Guttmacher Institute. Facts in Brief: Facts on Unintended Pregnancy in the United States (January 2015)

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

Source: Child Trends Institute. The Consequences of Unintended Childbearing, White Paper. (2007)

Does Intent Matter?

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

outcomes

2006 CDC Guidelines for Interconception Care

Less than 1 per 100

Implant IUDsFemale

sterilizationMale

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

ContraceptionFertility

Awareness Spermicides The sponge

Less effective About 25 pregnancies per 100 women each year

More effective Less than 1 pregnancy per 100 women each year

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

Comparing Birth Control Effectiveness

Intrauterine contraception (IUCs)

And announcing…

New Research on Emergency

ContraceptionCopper-T (Paragard

©) IUDella © Plan B © & other similar brands

How effective is it at preventing

pregnancy? Best Very Good Good

How effective is it at preventing STDs/STIs?

Not Effective Not

EffectiveNot

Effective

When do you use it? Up to 5 days after unprotected sex.

Up to 5 days after unprotected sex.

Up to 3 days after unprotected sex. Less effective on days 4 or 5, but you

can still use it.

Who can use it? All women, especially

women looking for effective, ongoing birth

control.

All women (unless breastfeeding). Less

effective for women with a BMI* over 35.

All women. Less effective for women with a BMI*

over 25. May not work for women with a BMI*

over 30.

How do you get it? Inserted by a health care provider.

Prescription from a health care provider.

Plan B is over the counter (OTC) for all; other brands are OTC for 17 year

olds & up.

ACTIVITY: WHAT WOULD YOU RECOMMEND?

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…

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

Title X FY 2015 Program Priorities

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

• 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.

The RLP Assessment

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.

Reproductive Life Planning (RLP)

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?

RLP at the Most Basic

• 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…)

Health Behavior

Consider Context of Health Behavior

• 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 Change

• Unified Theory of Behavior

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

Health Behavior Theory

Determinants of Behavior Intention

“My friends use birth control.”

“I am confident in my ability to use birth control correctly and consistently.”

“Using birth control is a positive and healthy choice for me.”

“I feel good about myself and think others feel positively about me using birth control.”

“I feel happy and relieved about choosing to use birth control.”

“I plan to use birth control.”

Moderators of Intention-Behavior Relationship

“I PLAN to use birth control.”

“I AM using birth control – correctly and consistently.”

“I know how and have the ability to use by birth control correctly and consistently.”

“I have access to birth control.”

“Using birth control correctly and consistently is very important to me.”

“Using birth control correctly and consistently is easy for me.”

Transtheoretical Model of Behavior Change

“I have no plans use birth control.”

“I am thinking about using birth control.”

“I will start using birth control soon.”

“I am using birth control.”

“I will continue using birth control.”

Transtheoretical Model of Behavior Change

Transtheoretical Model of Behavior Change

• Consciousness Raising– Increasing awareness about yourself

and information about a health behavior

• Environmental Reevaluation– Understanding how your unhealthy

behavior impacts those around you• Dramatic Relief– Experiencing strong emotional

reactions to events related to the unhealthy behavior

Transtheorical Model of Behavior Change

• Social Liberation– Noticing and using social conditions to

support healthy behavior change

• Self Reevaluation– Emotional and cognitive reappraisal of

your unhealthy behavior

• Self Liberation– Belief in your ability to change, and

commitment to act on that belief

Transtheorical Model of Behavior Change

• Helping Relationships– Trusting others and accepting their

support in your behavior change• Counter Conditioning– Replacing the unhealthy behavior with

more a healthier behavior and resulting positive experiences

Transtheorical Model of Behavior Change

• Reinforcement Management– Rewards for continuing to engage in

the healthy behavior and/or not engaging in the unhealthy one

• Stimulus Control– Avoiding or countering the people,

places, or things that support or encourage the unhealthy behavior

Transtheorical 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 this specific method of birth control. ***

3. Clients: Listen carefully to your counselors.

Role Play 1

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.

Motivational Interviewing (MI)

MI + RLP

A set of skills you can use to help your clients motivate themselves for success – including successfully using birth control and successfully planning pregnancies (if and when the client desires).

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

What is Motivational Interviewing (MI)?

• 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 Providers

Benefits of MI for Clients

• For individuals from communities that have traditionally been marginalized• Low-income communities• Communities of color

• For those who have otherwise had their individual power and autonomy taken away• Victims and survivors of trauma,

especially interpersonal violence

Empowering for Clients

Resist the righting reflex

Understand your client’s motivations

Listen to your client

Empower your client

Guiding Principles 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)

Behavioral Characteristics of MI

• RESPECTFUL

• OPTIMISTIC

• EMPATHETIC

• COLLABORATIVE

The Spirit 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

Another Way of Stating the Principles of 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

Behavioral Characteristics of MI

Role Play 2

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.

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

Expect – and Accept Ambivalence

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.

It Doesn’t Mean the Client Doesn’t Care

REWARDS

OBSTACLES

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

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

1 2 3 4 5 6 7 8 9 10

Ready, Willing, Able

Confidence Ruler

Least Most

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.

On One Hand…

Example

• 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

Don’t Jump Ahead!

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…”

Recognizing Change Talk

Intervention (MI)

Client assesses their own

GOALS

Client commits to

work on goals and makes a PLAN

CLIENT ACHIEVES GOALS or MODIFIES

BEHAVIORS

The Flow of Change Talk

Eliciting Information With

OARS

Open-ended questions

Affirmations

Reflections

Summaries

• 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.

Open-EndedQuestions/Statements

• Emphasize strengths • Nurture competency• Focus on

descriptions• Be genuine!

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

with an STI?

Affirmations

• 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.

Reflective Listening

A. SIMPLE– Repeat– Rephrase

B. COMPLEX– Double-sided (AND not

BUT)– Paraphrase– Metaphor– Continue the thought

C. AMPLIFIED– Exaggerate– Understate

Types of Reflections

• Collect the material that has been offered

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

• Transition to the next topic

Summaries

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

Rolling with Resistance

Thoughts, Ideas, Questions?

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

(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 Services

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

(information available in English/Spanish/Hmong)

Resources

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

Resources

• 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

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.

• 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.

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

Selected References