Meghan Benson, MPH, CHESDirector of Community Education
Anne Brosowsky-RothCommunity Education Resource
414-289-3767
Reproductive Life Planning & Motivational Interviewing
Safe Healthy Strong 2014Pre-Conference InstituteAugust 6, 2014
UW-Milwaukee Zilber School of Public Health
AboutPLANNED PARENTHOOD
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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
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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.
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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.
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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
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Source: the Contraceptive Choice Project
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
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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.
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Reproductive Life Planning - RLP
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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?
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BIRTH CONTROL:WHAT DO YOU KNOW?
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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
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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…)
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Consider the Context of Health Behavior
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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!
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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
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Unified Theory of Behavior
Determinants of Behavior Intention
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Unified Theory of Behavior
Moderators of Intention-Behavior Relationship
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Transtheoretical Model of Behavior Change
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Transtheoretical Model of Behavior Change
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Questions?
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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
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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.
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A set of skills you can use to help your clients motivate themselves for success.
MI + RLP
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More Information on Motivational Interviewing
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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
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
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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.
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Benefits of MI for Clients
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Guiding Principles of MI
Resist the righting reflex
Understand your client’s motivations
Listen to your client
Empower your client
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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)
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The Spirit of MI
RESPECTFUL
OPTIMISTIC
EMPATHETIC
COLLABORATIVE
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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
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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
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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
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Expect – and accept – Ambivalence
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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
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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
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12
34
56
78
910
On one hand…
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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
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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.
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The Flow ofChange Talk
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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…”
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• Open-ended questions• Affirmations• Reflections• Summaries
Eliciting Information With OARS
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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.
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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!
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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!
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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
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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.
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Rolling with Resistance
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Use amplified reflections Shift the focus Reframe Agreement – with a twist Stress personal choice Side with the negative
Thoughts, ideas, questions?
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What resources would you need to implement a discussion of RLP with your clients?
Are you ready?
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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)
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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
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Selected References
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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
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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.