Contraception among 16+ women: Qualitative research with healthcare providers
Summary of findings
Knowledge and Awareness Issues
Overall, healthcare providers demonstrated fairly good levels of knowledge about contraceptive types in relation to the basic facts about how each method works, the key ‘pros and cons’ and degree of efficacy, with no evidence of myths or incorrect information influencing beliefs, opinions or behaviour.
However, experience of, and familiarity with, the full range of contraception options was very varied across healthcare provider types, with corresponding variations in more detailed knowledge about each. There was also some evidence of less knowledge (and familiarity with), or of a degree of ‘information lag’, in relation to more recently-introduced contraceptive options (including some LARCs) in the case of some healthcare providers.
Knowledge of, and familiarity with, particular contraceptive methods had, unsurprisingly, a strong effect on the propensity of a provider/prescriber to discuss and advise on contraception options, as well as on prescribing behaviour, which tended to be a function of these two factors.
Awareness of the details of the NICE LARC guidelines was also variable across the sample. Although all healthcare providers knew of the existence of these, differences were apparent in relation to knowledge of (detailed) content, and it was apparent that there is a need to raise both awareness of the content of the guidelines themselves, and to ensure that clarity exists about their source (NICE, and not some other body or organisation).
A variety of information sources were being used in relation to contraception across the sample, with little perceived need amongst healthcare providers for more. However, there was some evidence that those who were least engaged (and knowledgeable) about this area might be more likely to update their knowledge if this was made easier for them, particularly where information was brought to them, rather than requiring them to seek it out themselves. For example, updating training on fitting, advising on various options being carried out at their practice or clinic, and at a convenient time, rather than at an external location on days when they were busy or unlikely to be available, and providing telephone or online (rapid response) support.
Prescribing behaviour was largely influenced by two factors – perceived efficacy of method and levels of user request. As a result, levels of awareness amongst users, as well as ‘popularity’ of particular methods amongst user networks (usage by friends, colleagues, family) appear to be largely responsible for driving the high prescribing rates of methods such as the combined pill, condoms and Emergency Hormonal Contraception (EHC). In addition, some of the more ‘Entrenched’ healthcare providers (see below for brief descriptions of this, and other, provider types identified in the research) have a tendency to prescribe the combined pill for a large number of users simply because of the stated efficacy levels (although they will also admit that these are user-dependent); this, along with user acquiescence, reduces their perceived need to discuss/prescribe alternative methods, including LARCs.
Some increased consideration of LARCs was apparent, however, amongst a number of healthcare providers, especially the ‘Committed’ and the ‘Pragmatic’ types, not least because of ‘user failure’ (to use the method properly) of the combined pill.
Overall, the frequency of prescribing LARCs was not especially high, having reached only medium levels (in comparison to the more ‘popular’ methods listed above) for the majority of prescribing providers. This was seen to be due to both variability in user demand, and to perceived levels of user-resistance to LARCs, making some a harder ‘sell’ for providers; in some instances, this was exacerbated by healthcare provider concerns about possible side-effects, notably in relation to prescribing the contraceptive injection for younger audiences.
Where LARCs were prescribed, the main preference was for prescribing either the implant or injection amongst healthcare providers, largely prompted by user requests and the degree of familiarity which that particular provider had with the method in question.
Lower user interest and lower perceived efficacy had the effect, then, of making certain contraceptive methods much less likely to be considered by most healthcare providers, notably sterilisation, the contraceptive patch, the diaphragm, the female condom and natural family planning.
Focus on Wider Choice/LARCs
Whilst awareness was generally high amongst most healthcare providers in relation to the ‘ideal’ consultation approach (discussing a range of options, offering choice to users), the degree to which this approach was implemented, particularly in relation to discussing LARC options was variable.
Overall, Healthcare Providers could be largely split into 3 main types:
- Committed - those committed to discussing choice and promoting LARCs wherever possible; these typically tended to be contraceptive specialists (family planning clinic nurses, for example).
- Pragmatic - those who aim to discuss choice and promote LARCs, but are constrained by the practicalities of the consultation process, so that suitability (for the user) may not be fully established and/or the range of options not covered effectively. This was often because the key focus was to ensure that a contraceptive method is used at all; this type was found principally amongst GPs and practice nurses.
- Entrenched - those who stick to familiar prescribing habits, and tend to follow a patient-led preference; they also typically focus on the combined pill, since this is usually the easiest method to ‘sell’ to users. This type typically displays a lower awareness of both the full range of choice of options, and of LARCs in particular, an attitude arising from both lower knowledge and familiarity with LARCs, and because they tend to see contraceptive advice as only one facet of their role; again, both GPs and practice nurses could fall into this category.
- Pharmacists and school nurses tended to form a separate group of healthcare providers, with somewhat different levels of knowledge, attitudes and behaviours, given their respective restricted remits to prescribe and/or advise. However both remain useful channels for information distribution, and represent opportunities for information dissemination, especially in the form of simple handouts.
Implications for a Campaign
The majority of healthcare providers in the sample were positive about a public campaign on choice in relation to contraceptive options, recognising that raising awareness of options amongst the target audience would be helpful. It perceived that users would present with a wider range of suggestions for discussion, but also in general terms it was also felt that such a campaign would offer a valuable reference point from which to extend the discussion with all users about different methods of contraception, providing the opportunity to introduce (and promote the benefits of) LARCs. Such a campaign is also likely to be critical in shifting the attitudes and behaviours of ‘Entrenched’ provider types, given their user-led orientation.
Assuming that such a campaign did run, a variety of issues and opportunities were identified which might help to minimise concern (about capacity to respond appropriately) and assist in service delivery; these included:
- Improved availability of training (convenient times and locations, number of opportunities) in delivering LARCs (supplying and fitting).
- Improved support for certain healthcare providers so that sufficient services are set in place to meet increased demand (for example, support, training and ‘up skilling’ for Practice Nurses to support GPs).
- Improving detailed knowledge of LARCs amongst healthcare providers so that they are knowledgeable and confident in consultations with users; for example, providing broader information of user experiences for those who are less familiar with these; providing a rationale (or even a script), especially for Entrenched types, to facilitate a discussion of how LARCs represent a ‘better version’ of the pill for some women.
Improved tools for dealing with the volume of information around alternative methods. This would include:
- a categorising each tool to ensure that the suitability of particular options for the individual user is established effectively (and unsuitable options quickly eliminated), and that sufficient time can be devoted to exploring and explaining these options.
- a ‘signposting’ or ‘top level information’ tool which can help both within the consultation and be passed on to users to help navigate more detailed info which might be targeted at them; this might take the form of a print-out with bullet points (and where to look for more information/advice) which is handed out by the GP or Practice Nurse.
The overall objective of the research was to inform decisions about the type and nature of marketing activity which should be undertaken in this field so that the service available to contraception users can be improved, and provision of the widest possible range of contraception options, including LARCs, effected.
Achieving this objective involved exploring:
- Healthcare providers’ knowledge about the different contraceptive options, current guidelines and service pathways.
- Any myths and negative perceptions about the different contraceptive options.
- Influential sources of information used by health professionals and why these are valued.
- Prescribing preferences and any barriers to offering a wide range of contraceptive choices to women.
- The impact of the revised Quality and Outcomes Framework regarding contraception.
- Responses to a campaign aimed at increasing user awareness of a range of contraceptive choice.
- Training needs and any barriers to training.
The Department of Health (DH) have a key policy objective to increase and improve access to all methods of contraception, which should thereby also increase uptake of the more effective methods (that is, the long acting reversible methods/’LARCs’ – or specifically the implant, the injection, IUS and IUD).
To achieve this, DH need to improve knowledge of the both health providers and the user audience about the range of contraceptive options available. Communications and marketing activity is therefore being developed aimed at improving knowledge amongst the audience groups. To help inform development of this activity, research was required to fully understand current knowledge, attitudes and perceptions in relation to the range of contraceptive choices which are available to women in England.
Healthcare providers demonstrated fairly good levels of knowledge about contraceptive types in relation to the basic facts about how each method works, the key ‘pros and cons’ and degree of efficacy, with no evidence of myths or incorrect information influencing beliefs, opinions or behaviour.
Those who were least engaged (and knowledgeable) might be more likely to update their knowledge if this was made easier for them.
Work with healthcare providers only.
40 depth interviews: 10 face to face and 30 telephone
Data collection methodology