pediatrics-1984-jay-126-31

126 PEDIATRICS Vol. 73 No. 2 February 1984

Effect of Peer Counselors on AdolescentCompliance in Use of Oral Contraceptives

M. Susan Jay, MD, Robert H. DuRant, MA, Tamsen Shoffitt, RN,Charles W. Linder, MD, and Iris F. Liii, MD

From the Departments of Pediatrics, Medical College of Georgia, Augusta; and StanfordMedical School, Stanford, California

ABSTRACT. Poor compliance with contraceptive regi-mens has been shown to be an important antecedent ofadolescent pregnancy. The purpose of this study was totest prospectively the effect of a peer v nurse counselingprogram on adolescent compliance with the use of oralcontraceptives. Fifty-seven females aged 14 to 19 yearsfrom a lower socioeconomic background were randomlyassigned to a peer (n = 26) or nurse (n = 31) group. Atthe initial visit and at 1-, 2-, and 4-month follow-upvisits, subjects received Ortho-Novum 1/35 combinedwith a tablet marker and were counseled by a nurse orpeer. Noncompliance was measured using a Guttmanscale consisting of: (1) avoidance of pregnancy, (2) ap-pointment adherence, (3) pill count, and (4) urinaryfluorescence for riboflavin. At the first and second follow-ups, the adolescents counseled by a peer had a signifi-cantly (P .038) lower noncompliance level than thenurse-counseled group. Adolescents with more frequentsexual activity (P .027), with one sexual partner (P .05) from one another.

TABLE 2. Social-Psychological Indicators for Experi-mental Groups*

Nurse-Counseled Peer-CounseledGroup Group

Piers-Harris self-con- 62.1 8.3 62.2 7.5cept scale

Coddington life crisis 320.3 172.4 294.9 208.5events scale

Yeaworths life change 367.5 236.1 385.2 228.3events scale

Autonomy scale 2.0 1.4 2.6 1.4Dissatisfaction with 1.6 1.7 1.5 1.1

previous medicalcare scale

* Values are means SD. Based on analysis of variancetests, values for these pretest variables were not satisti-cally significant (P > .05) from one another.

at Indonesia:AAP Sponsored on March 28, 2015pediatrics.aappublications.orgDownloaded from

128 PEER COUNSELORS AND CONTRACEPTIVES

contraceptives from either a nurse or peer coun-selor. The subjects did not necessarily see the samenurse or peer counselor at every follow-up visit.However, continuity of counselors was similar inboth experimental groups.

Urine samples were tested for the presence ofriboflavin by placing them in front of a 375Multraviolet light source (Gelman Instrument Co,model 51438).23 The adolescents urine plus that ofpositive and negative control subjects were evalu-ated for fluorescence in a double-blind fashion by apanel of three independent observers.

Noncompliance Scale

Noncompliance was measured with a four-factorGuttman scale that consisted of the following: (1)whether the subject became pregnant during theprevious month, (2) whether she missed her ap-pointment, (3) whether she missed taking three ormore oral contraceptives during the month, and (4)absence of urinary fluorescence at the time of fol-low-up. Based on a Guttman scale analysis, thesefour items had a coefficient of reproducibility of0.96 and a coefficient of scalability of 0.84.24 Thecoefficient of reproducibility is a measure of theextent to which a respondents scale score is apredictor of ones response pattern. A score ofgreater than 0.90 is considered a valid scale. Thecoefficient of scalability measures the degree thatthe scale is unidimensional and cumulative. Thisscore should be well above 0.60.25

Of the 57 subjects in the study, 26 who wererandomly chosen at random follow-up periods hadserum samples tested for the presence of norethin-drone levels. Serum norethindrone was measuredusing a radioimmunoassay method by the Endocri-nology Laboratory at the Medical College of Geor-gia.2m The 26 subjects had a mean norethindronelevel of 694.75 46.6; SEM was 23.3 and coefficientof variation was 6.7%. The serum norethindronetest was used to ensure that the urinary fluores-cence test was an accurate measure of compliancewith an oral contraceptive regimen. Based on aFishers exact test, a high degree of association (P: .02) was found between the serum norethindronetest and urinary fluorescence.3#{176}

Statistical Analysis

The two experimental groups pretest measure-ments were compared using a one-way analysis ofvariance test. The posttest measurements at 1-, 2-,and 4-month follow-ups were analyzed using one-and two-way analysis of variance tests with aregression approach.25 The regression approach as-sesses each effect in the analysis of variance model

after all other main and interaction effects have

been adjusted.

RESULTS

There were no significant (P > .05) differencesbetween the nurse-counseled and peer-counseledgroups in any of the pretest measurements (Tables1 and 2). This suggests that the subjects in bothgroups were similar with regard to these variablesprior to the institution of the treatment effect (peerV nurse counseling).

At the first month follow-up, the subjects in thepeer-counseled group had significantly (P .038)lower noncompliance than the nurse-counselorgroup (Table 3). When additional pretest factorswere entered into the analysis of variance model todetermine whether they influenced the response tonurse v peer counselors, worrying about becomingpregnant significantly (P .01) interacted with thetreatment effect. Adolescents in the nurse-coun-seled group who stated that they worried that theymight become pregnant had significantly higherlevels of noncompliance. In the peer group, thedifference between worriers and nonworriers wasnot significant. These findings suggest that peercounselors may have a positive influence on thissubgroup of adolescents.

Frequency of sexual activity also significantly (P .027) interacted with the treatment groups at thefirst month follow-up. Adolescents in the nurse-counseled group who had sexual intercourse once aweek or less had slightly higher noncompliancethan those adolescents in the peer-counseled groupwith the same frequency of sexual activity. How-ever, adolescents who had sexual intercourse twoor more times a week and were counseled by a nursehad significantly higher levels of noncompliancethan any of the other adolescents.

At the second month follow-up, the nurse-coun-seled group continued to have higher levels of non-compliance than the peer-counseled group. Thisdifference was statistically significant when con-trolling for the effects of number of sexual partners(P .006) and frequency of sexual activity (P .044). Similar to the findings at the first monthfollow-up, there was little difference in noncompli-ance between nurse-counseled and peer-counseledadolescents having sex once a week or less. How-ever, among adolescents having sexual intercoursetwo or more times a week, those counseled by anurse had significantly (P .044) higher levels ofnoncompliance than those counseled by a peer atthe second month follow-up. The number of sexualpartners also significantly (P .03) interacted withthe treatment groups. Adolescents with one sexualpartner had the same level of noncompliance, re-


1st mo follow-up2nd mo follow-up4th mo follow-up

Total attrition rate

ARTIClES 129

TABLE 3. Noncompliance Levels for ExperimentaiGroups at Each Follow-up Period*Nurse-Counseled

- Group __________Peer-Counseled

_____Group

1.68t 1.22 (N = 31) 1.OOt 1.16 (N = 26)1.18 1.10 (N = 22) 0.95 0.78 (N = 22)

1.06 1.11 (N = 18) 0.85 0.98 (N = 20)42% 23%

* Values are means SD.tFratio = 4.531; P .038.:1:F ratio = 8.888; P .006 when controlling for number of sexual partners; and F ratio =4.331, P .044 when controlling for sexual frequency. P .001.

gardless of which counseling group they were in.The adolescents in the peer-counseled group withno sexual partners in the last 3 months had signifi-cantly higher noncompliance levels than the ado-lescents with two or more partners. In contrast, thesubjects with no sexual partners in the preceding 3months appeared to respond better to nurse coun-seling than peer counseling. The adolescents in thenurse-counseled group with two or more sexualpartners had the highest level of noncompliance atthe second month follow-up.

At the fourth month follow-up, the nurse-coiin-seled group still had higher levels of noncompliancethan the peer-counseled group, although the differ-ences were not statistically significant (Table 3).However, the nurse-counseled group had signifi-cantly (P .001) higher attrition (42% v 23%) fromthe study than the peer-counseled group by thefourth month follow-up. Attrition was defined asfailing to keep the second rescheduled broken ap-pointment or discontinuing the oral contraceptiveregimen.

Unlike the first and second month follow-ups,none of the indicators of sexual behavior interactedwith the treatment. effect at the fourth month fol-low-up. Yet, a social psychological indicator ofhopelessness significantly (P .036) interactedwith the counseling groups effect on compliance.Adolescent females in the nurse-counseled groupwho felt it was no use trying to get anywhere in lifehad significantly higher levels of noncompliance bythe fourth month follow-up; yet, adolescents withfeeling of hopelessness who had been counseled bya peer had substantially lower levels of noncompli-ance.

DISCUSSION

Prior to being assigned to treatment groups, thesubjects were pretested on a variety of measures.The purpose of this was to ensure that other factorspreviously implicated as possible correlates withnoncompliance or adolescent pregnancy did notdiffer between the groups.68922 The subjects in

both the peer-counseled and nurse-counseledgroups were found to be similar in sexual andphysical development, sexual history, self-concept,autonomy, life crisis events, and satisfaction withprevious medical care.

At the first month follow-up, our peer-counseledgroup had significantly lower levels of noncompli-ance than our nurse-counseled group. Two addi-tional factors were found to influence the effect ofthe type of counselor on noncompliance. Adoles-cents who stated that they worried about becomingpregnant had higher levels of noncompliance whencounseled by a nurse than by a peer. Those adoles-cents who expressed worry that they might becomepregnant may represent girls who, due to theirprevious sexual and contraceptive experiences,knew that they might have difficulty rememberingto take their oral contraceptives and, in turn, be athigher risk of becoming pregnant. However, thefindings also suggest that being counseled by a peermay have had a positive impact on this subgroupof adolescents. In addition, adolescents who re-ported having sex two or more times a week wereat higher risk of noncompliance when counseled bya nurse, but not when counseled by a peer.

At the second month follow-up, when the effectof previous sexual activity was statistically con-trolled, the peer-counseled group continued to havesignificantly lower levels of noncompliance. In ad-dition, two factors interacted with the type of coun-selors effect on compliance. Similar to the findingsduring the first month follow-up, subjects havingsexual intercourse more than once weekly had sig-nificantly higher levels of noncompliance than ad-olescents having sex once a week or less if theywere counseled by a nurse. However, there was littledifference between the groups that were counseledby a peer. We also found that the number of sexualpartners that an adolescent had in the previous 3months influenced her response to a peer or nursecounselor. Adolescents with more stable relation-ships, having only one sexual partner over a 3-

month period, had the same level of compliance


130 PEER COUNSELORS AND CONTRACEPTIVES

regardless of whether counseled by a nurse or apeer. The adolescent girls with no sexual partnersin the 3-month period prior to the study who werecounseled by a peer had significantly higher levelsof noncompliance than similar subjects counseledby a nurse. In contrast, subjects with the mostsexual experience, having two or more sexual part-ners, had extremely low levels of noncompliancewhen counseled by a peer, but extremely high levelsof noncompliance when counseled by a nurse. Bothof the above relationships suggest that adolescentswith little sexual experience may benefit from theexperience, professionalism, and possible authoritythat a nurse may demonstrate during the initialmonths of contraceptive use. However, among ad-olescents with more sexual and contraceptive ex-perience, the introduction of a peer counselor ap-peared to enhance compliance. This finding may beexplained by the fact that adolescents with greatersexual experience may be more receptive to positiverole models such as a peer provider.

At the fourth month follow-up, the nurse-coun-seled group continued to have higher levels of non-compliance than the peer-counseled group, al-though the differences were not statistically sig-nificant. However, by 4 months a significantlyhigher proportion of the adolescents in the nurse-counseled group than in the peer-counseled groupdiscontinued taking oral contraceptives. During thefirst 2 months of follow-up, previous sexual activityhad the greatest influence on how the adolescentsresponded to nurse v peer counseling. By the fourthmonth a social-psychological indicator had an im-pact on compliance. We found that among adoles-cents who felt hopeless or apathetic3 about theirfuture, those counseled by a peer had significantlylower levels of noncompliance than those who re-ceived nurse counseling. Ryan and Sweeney32 pointout that among adolescents who have no hope forthe future, pregnancy does not appear to be a threatto their future life-style and thus may be an ac-ceptable alternative. They argue that until thissubgroup of adolescents are able to have their hopesfor the future realistically threatened by pregnancy,they will continue to seek personal fulfillmentthrough childbearing. The findings from our studysuggest that the use of peer counselors may bebeneficial in helping these high-risk adolescentsdeal with their hopelessness by providing them withpositive role models. This, in turn, may increasetheir compliance with contraceptive regimens.

In confirmation of previous reports,6 the findingsfrom our study suggest that the nature of the inter-action between the health care provider and thepatient, combined with the adolescents sexual be-havior and social-psychological status, may influ-ence how compliant she will be with her oral con-

traceptive regimen. More specifically, it appearsfrom our study that peer counselors can work asadjuncts to the health care team in providing infor-mation, education, and counseling in the use of oralcontraceptives. These findings also suggest that theimpact of peer counselors on adolescent compliancemay be greatest during the first 2 months afterinitiation of oral contraceptives. This is significantas most of the adolescents who do become noncom-pliant do so during the first few months after takingoral contraceptives.67 Of three adolescents who be-came pregnant during our study, one pregnancyoccurred in each group during the first month fol-low-up, and one additional pregnancy occurred inthe nurse-counseled group during the secondmonth. We are now aware that knowledge of con-traceptive availability is not enough to preventadolescent pregnancy, and other modalities mustbe used to reach our adolescent population. Asadolescents seek contraception, structure and guid-ance are needed and peer counselors can frequentlyfulfill these needs in a nonthreatening way.

It would have been desirable to have studied thisproblem with a larger sample size over a longerfollow-up period. However, this prospective studywas conducted with greater experimental controland for longer follow-up periods than previous re-ports. In addition, inasmuch as this sample wasdrawn from a lower socioeconomic population con-sidered to be at high risk of adolescent pregnancy,it would be beneficial to test prospectively the in-fluence of peer counselors on compliance with oralcontraceptive use in other groups of adolescents.

ACKNOWLEDGMENTSThis work was funded, in part, by a grant from the

Georgia Department of Human Resources.We would like to thank Dr V. B. Mahesh and J. 0.

Ellegood for completing the serum norethindrone testsand Kathy Pilcher for assistance with the manuscript.

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1984;73;126PediatricsM. Susan Jay, Robert H. DuRant, Tamsen Shoffitt, Charles W. Linder and Iris F. Litt

Effect of Peer Counselors on Adolescent Compliance in Use of Oral Contraceptives

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Effect of Peer Counselors on Adolescent Compliance in Use of Oral Contraceptives

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