Making sound choices: boosting uptake of long-acting reversible contraceptives
Australia lags behind comparable nations for uptake of one of the most effective forms of contraception on the market – long-acting reversible contraceptives, or LARC. A recent study involving multiple researchers from the Monash School of Public Health and Preventive Medicine (SPHPM) has sought to better understand what specific features of LARC appeal to Australian women, in a bid to help health professionals and government boost rates. The study was published in the European Journal of Contraception & Reproductive Health Care.
LARC include the well-known intrauterine devices and hormonal implants. Once inserted, they provide effective long-term contraception for many years, until they are removed or replaced.
However, use of the oral contraceptive pill (OCP) far outstrips that of LARC in Australia. This is despite an obvious fallibility that is known to reduce the pill’s overall efficacy – the need to remember to take it every day. LARC also have equal or lower side-effect profiles than OCP.
Despite being subsidised by the government, just 10.8 per cent of Australian women using contraception have opted for a LARC. Rates of LARC uptake are much higher internationally, with over 30 per cent of women in Sweden using them.
Senior author Professor Danielle Mazza, who heads up the Monash Department of General Practice within SPHPM, says, “While we certainly don’t want to pressure women into choosing LARC, it’s really important that both health professionals and women understand the benefits of all available options, and that women are given the option of having a LARC if they choose to. Given the high stakes of a contraceptive failure, the extremely high efficacy of LARC is an obvious selling point. Which then begs the questions, why are uptake rates so low here, and what can be done to improve them?”
One of the biggest barriers is a lack of accessibility. GP providers trained in LARC insertion, particularly intrauterine insertion, are hard to find, with many women waiting weeks to months for appointments. Unlike OCP, which can be paid for as needed, costs associated with LARCs are borne in one lump sum upon insertion.
First author Professor Marion Haas is a health economist from the University of Technology Sydney. She brought her expertise to the design of the study’s discrete choice experiment, a design popular in health economic analyses that establish consumer preferences. These typically involve survey questions, presented in conjunction with small tasks in which respondents must choose between two options.
In this experiment, participants worked through 12 choice tasks, each requiring their stated preference between two described contraceptive options. After each choice, they were also asked whether they would swap from their current contraception to their chosen option.
Professor Haas says, “There are lots of considerations when weighing up contraceptive options. Efficacy is one big one, but impact on monthly bleeding, mood, affordability, whether your GP or health provider advocates for you to change, and the risk of adverse health events are all common and valid considerations. It’s important to understand the low uptake of LARC here in that context.”
645 women were recruited via an online survey provider, with 621 successfully completing the survey in September 2020.
The results show that Australian women are guided by the recommendation of their GP, and have strong preferences for contraceptive methods that are effective, safe, and don’t negatively affect their mood. High cost was a disincentive to product choice; this result was more pronounced for LARC compared to OC.
Professor Mazza says, “This tells us that to increase uptake, the cost of LARC would need to be reduced to below the average annual cost of OCP.
“The implication from our finding that GPs can influence health behaviour is that their recommendation that a woman consider a LARC is an effective means of increasing their use.
“It’s really important that health care professionals understand and communicate to women accurate information regarding LARC. Our findings act as a roadmap about what women are considering when they are thinking about LARC use. GPS can use these points to help guide them when they provide information about LARC to make sure all the woman’s concerns are addressed.
“Empowering women to make fully informed choices that meet their personal priorities is an important challenge in this space. It’s been a privilege to be part of a study that assists with that; I’m keen to take the next steps in translating this work into action.”
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