Particular promotion of the intrauterine system to "vulnerable" adolescents: a qualitative exploration of hormonal contraceptive prescription practices.

内容摘要

Previous studies have suggested that the intrauterine system increases the risk of depression, particularly in adolescents. However, these studies relied on national registry data collected at a time when medical guidelines discouraged adolescent use of this contraceptive method. As a result, the adolescents who appeared in these registries represented an atypical group who had this contraceptive prescribed against medical recommendations. Consequently, unknown or unmeasured participant characteristics may have introduced confounding variables and influenced conclusions. Although prescription guidelines for intrauterine systems now include adolescents, selective prescribing may persist. If so, it could affect future studies on hormonal contraceptives, even though the decision is clinically sound. We thus aimed to explore current contraceptive prescription practices, investigating user characteristics, policies, and contextual factors that might influence prescribing the intrauterine system rather than other hormonal contraceptive products, or vice versa. We conducted focus group interviews with 23 healthcare professionals employed at six health centers in Norway, prescribing hormonal contraceptive drugs to adolescent women. We used thematic analysis to identify factors that can influence which products are recommended and requested. Our analysis generated three themes: "Old conceptions die hard" describes skepticism among family doctors and mothers regarding adolescent use of the intrauterine system, "Particular promotion of the intrauterine system to "vulnerable" adolescents" outlines the practice of healthcare professionals recommending this contraceptive method to individuals identified as vulnerable, and "What tips the scale: Pros, peeves and other people" discusses influences on adolescents' contraceptive choice. This exploratory study suggests that both prescription practices and personal preferences influence choice of contraceptive product, and that it is not arbitrary who has the intrauterine device inserted. Future quantitative research should incorporate the factors identified in this exploration, to minimize their confounding effects when aiming to draw causal conclusions on the effects of the intrauterine system on mental health. The intrauterine system is an effective, easy-to-use hormonal contraceptive method. However, some have raised concerns that it can cause symptoms of depression in adolescents. We believe these concerns to be misguided, as they stem from studies on teenage users conducted at a time when medical guidelines advised against this contraceptive method in adolescents. Consequently, the teenagers included in these studies may already have had medical or mental health conditions that led clinicians to prescribe the intrauterine system despite the guidelines. These underlying conditions may also explain the later development of depressive symptoms, which may then have been incorrectly attributed to using the intrauterine system. Recommendations for the intrauterine system now include adolescent women, but if different contraceptives are still selectively prescribed, the conclusions we draw when researching these drugs and mental health could be affected.We therefore explored current prescription practices, interviewing healthcare professionals at health centers for adolescents. We aimed to identify factors that could influence which type of contraception adolescent women prefer and what healthcare professionals prefer to prescribe.Our informants said that several factors can still influence who has the intrauterine system prescribed. Most notably, specific individual characteristics were described as leading to some adolescents being viewed as “vulnerable”. For these adolescents the healthcare professionals reported making additional efforts to recommend the intrauterine system over other types of contraception, because of its effectiveness and user friendliness.This study highlights the need for assessing background factors when researching the relationship between hormonal contraceptives and mental health.