Interindividual variation and drug interactions with hormonal steroid contraceptives.

Large interindividual differences occur in the plasma concentration of contraceptive steroids. With the present tendency to decrease the dose of progestagen and oestrogen any factor which reduces the bioavailability of the lower dose preparations becomes very important. The possibility that other drugs and environmental chemicals may interact with contraceptive steroids is currently being investigated. Clinical reports suggest that the most important interacting drugs are the antituberculosis agent rifampicin, anticonvulsants and antibiotics. In the case of the first two, evidence is available suggesting that microsomal enzyme induction, either in the liver or the gut wall, is the operative mechanism. Antibiotics interfere with the pharmacokinetics of contraceptive steroids by interfering with their enterohepatic circulation in animal species: whether this is operative in man is still unclear. Other environmental and constitutional factors such as smoking, variations in diet, and concurrent disease may alter the disposition of contraceptive steroids and affect response accordingly. Additional studies are needed to estimate the significance of such interactions.

PIP: There has been little study on the clinical pharmacology of OCs (oral contraceptives). Studies have shown that large interindividual differences occur in the plasma concentration of contraceptive steroids, indicating a difference in metabolism. As estrogen and progestogen content of OCs are being continually lowered, any substance which reduces the bioavailability of the steroids within OCs may actually lower contraceptive efficacy also. The literature is studied for mention of drug and other environmental chemical interactions with OCs. 3 main groups of drugs have been shown to react adversely with OCs: 1) antituberculous drugs, especially rifampicin; 2) anticonvulsant drugs; and 3) antibiotics. Studies on all 3 of these types of drugs are cited along with advice to patients concerning each category of drug. For the 1st 2 types of drugs, microsomal enzyme induction in either the liver or the gut wall is the operative mechanism. Antibiotics interfere with enterohepatic circulation in animal species. It is believed that smoking and diet may also affect the efficacy of OCs. Probably only individuals with low plasma concentrations of the contraceptive steroids are at serious risk from drug and environmental interactions.

National drug policy and rational drug use: a model curriculum for developing countries.

Of the world's five billion people, 75% of whom live in developing countries, 25-50% have little or no access to basic pharmaceuticals. To ensure an adequate supply of safe and effective drugs of good quality, a national drug policy (NDP) should be incorporated into the national health policy. Elements of a NDP include: identification of therapeutic needs; objective selection of essential drugs; drug supply and distribution system; effective legislation and regulation; quality assurance; manpower development; and dissemination of drug-related information. Drug availability does not ensure their rational prescribing or dispensing or appropriate patient use. It is proposed that a flexible multi-disciplinary curriculum be established for healthcare professionals and students and public policy formulators to provide instruction in NDP elements and the principles of rational drug use. Such courses may stimulate multi-disciplinary drug-related scholarly activities.

Drug use and the role of patients and prescribers.

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

PIP: In the effort to improve rational drug use in local or national settings, especially in developing countries, the behavior of prescribers and users is the subject of the least research. The effectiveness of drugs depends on a complex set of factors involved in the situation of prescription and acquisition. One aspect that needs examination is the information given to prescribers by drug advertisers and detailers, a deficiency being addressed by an international network of prescribers. In many countries, the largest outlet for drugs is the private sector pharmacies, where drugs are often dispensed without prescription. A simple inexpensive way of researching prescription behavior is to use fictitious tracers to follow case management of given conditions, such as infant diarrhea. There are many factors involved in prescribing; the process must be studied with an epidemiologic approach, i.e., by description, analysis, intervention and evaluation. Standard treatment schedules, essential drugs lists, targeted intervention with treatment guidelines should be audited by local therapeutic committees. Drug information should also be scientifically evaluated by the same analytical principles. The experimental method of group randomization is suggested as a feasible choice for developing countries. In this technique groups of physicians are observed or interviewed, and quantitative outcome data are collected. Behavior of individual users is best studied by combining anthropological and biomedical approaches, from the case-study perspective. An example of a problem amenable to this approach is the possible use of shorter courses of antibiotic treatment to lessen the risk of development of resistant organisms.

A nonmedical approach to fertility reduction. An experimental contraceptive service unit.

PIP: A preliminary report if given of results of 3 walk-up Contraceptive Service (CS) Units started in Forsyth County, North Carolina, by the Behavioral Science Center of Bowman Gray School of Medicine that tried through an experimental and nonmedical approach to reduce fertility among young poverty-level females by focusing on young sexually active males. 552 new and 874 returning clients visited the CS units during the first 7 months of the experiment. 90% new and 98% returning clients have been male. The first clinic was opened September 1, 1968, 3 hours each evening except Sunday. In November a second clinic was opened in March. Each was staffed by a nonmedical trained counselor. A choice of condoms, foam, or jelly and instruction in proper technics in using these methods provided at no cost. Male clients have been highly responsive, entering freely into discussion. Objections to mechanical methods were removed by instruction in proper use. Most requested condoms and foam. Location accounts different degrees of success and will be evaluated in a future report. CS effectiveness should be measured in lower venereal disease incidence. Further evaluation will include excess fertility analysis and numerator anaylsis.^ieng

The role of pharmaceuticals in the total health care of developing countries.

PIP: Following an overview of the less developed countries (LDCs) and their health problems, attention is directed to what pharmaceutical companies have been doing to develop tropical disease medicinals: past and current programs for the development of pharmaceuticals; the relationship of pharmaceuticals to other health problems; criticisms of the pharmaceutical industry; problems and constraints in developing drugs by pharmaceutical firms, particularly for tropical diseases; and strengthening incentives to pursue tropical medicine research in the future. There are 31 countries in the less developed category and they have 4 things in common: poverty; a high birthrate; a young population, and a low life expectancy. At the top of the list of the major health problems in developing countries are malaria, diarrheal diseases, and malnutrition. For malaria, there is a need for something new for chloroquine resistant infections, but research looks promising. Meanwhile, the use of presently available medications in much of the world would go far towards alleviating suffering and death from this disease. For diarrheal diseases and malnutrition the principal problems lie elsewhere than with development of new pharmaceuticals. For tuberculosis and leprosy, the 4th and 5th major health problems, therapy has improved markedly in recent years, yet there is room for improvement. Of the sexually transmitted diseases, only for sexually transmitted herpes is the industry missing a solution. On balance, it seems clear that the need for new pharmaceuticals, although important, is not as critical as some of the other needs of the LDCs. If this individual is correct in maintaining that the most important problems in the LDCs are pure water, adequate food, basic sanitation, and a distribution system for already available pharmaceuticals, then the question is why is the drug industry singled out for so much criticism. The principal charges, which are discussed in detail, are as follows: inadequate research on the endemic diseases of the developing and least developed countries; the practice of "dumping" drugs in developing countries that do not sell or sell for different indications at home; labeling of products differently than in the US; permitting over the counter sales of drugs that a prescription only goods in the US; selling products whose stated expiration date has passed; and charging high prices and reaping excessive profits. The critics are the UN agencies, consumer groups, trade unions, and media writers. Much of what is said is in defense of the pharmaceutical industry. but shortcomings are also noted.^ieng

Safety implications of transferring the oral contraceptive from prescription-only to over-the-counter status.

The idea of making oral contraceptives available without prescription has a long history, and has been recently revived in the US and the UK. High dose oral contraceptives have generally been replaced by low dose formulations and, subsequently, most cardiovascular risks have been reduced and a protection against ovarian and uterine cancers has been consistently demonstrated. Oral contraceptive compliance, however, continues to be a problem, but there is no reason to assume that wise practice would be any more or less if oral contraceptives were available over-the-counter (OTC). Some countries have introduced alternatives to prescription-only oral contraceptives, whereby nurses, midwives, social workers and/or pharmacists are incorporated into the distribution process. This article concludes that the balance of risks and benefits is in favour of OTC access for oral contraceptives.

PIP: US and UK Family planning providers have revived the debate of whether or not to make oral contraceptives (OCs) available over-the-counter. Decreased hormone doses in OCs have reduced most cardiovascular risk and protect against ovarian and uterine cancers. An advantage of progestogen-only pills is that they can be used safely by smokers and breast-feeding women. In the US, an OC prescription provides many women from minority groups and single mothers who receive OCs from family planning programs with their only access to health care. Since the cost of an OC prescription is so high, women receiving subsidized OCs tend not to switch to other methods. User compliance remains a problem even with prescription. One study found a failure rate of up to 11% for OC users younger than 18. Poor user compliance would as likely be a problem if OCs were available over-the-counter. Two public health specialists with the University of California, Berkeley, echo the recommendation that emergency contraception (2 high-dose OC pills initially followed by 2 more pills 12 hours later) should be available without prescription, which can be managed separately from the routine use of OCs. Pharmacists could be trained to explain OCs, discuss possible contraindications, and provide reference materials to potential OC users. Nurses, midwives, or social workers could be responsible for OC prescription. In the UK, nurses can already prescribe drugs more complicated and potentially dangerous than OCs. Making OCs available over-the-counter could improve women's health, make OCs more easily available, free some professional and financial resources that might then focus on other areas (e.g., diagnosis and treatment of sexually transmitted diseases in the young), and boost confidence of OC users. If OCs are on the shelf next to aspirin and antihistamines, they will be perceived, as they well should be, as a well-tolerated, easy-to-use medicine.

Worldwide impact of oral rehydration therapy.

Oral rehydration therapy (ORT) has had a dramatic global impact. The worldwide consequences of this therapy are discussed in four categories: (1) adoption of ORT as the primary therapy for acute dehydrating diarrhea; (2) establishment of national ORT programs; (3) scientific knowledge gained from studies into intestinal absorption of oral rehydration solutions; and (4) implications of ORT for the next decade. The Diarrheal Disease Control Program has been assigned a high priority by the World Health Organization. It now includes 99% of the population of the developing world, although it is not uniformly implemented. Because knowledge of how to use ORT parallels implementation, it is hoped that expanded training of community health workers will increase implementation. In addition, specific indications for ORT need further study and refinement so that community health workers may learn to distinguish between diarrheal episodes that require such therapy and those that do not. Better scientific understanding of intestinal absorption of ORT fluids has led to the development of new formulations that enhance absorption of nutrients and repletion of electrolytes. The optimal composition of such revised solutions has yet to be established. In addition to these improvements in utilization, distribution, education, and application of ORT, other measures to reduce the morbidity and mortality from diarrhea can be expected in the areas of better infant feeding practices, improved sanitation, management of persistent diarrhea, targeted therapy for particular groups of infants at high risk, and immunization.

PIP: The impact of oral rehydration therapy (ORT) on the estimated 5 million deaths of children yearly from acute dehydrating diarrhea is discussed in terms of worldwide adoption of ORT as primary therapy; establishment of national ORT programs; new scientific knowledge of intestinal absorption of ORT solutions; and implications of ORT for the next decade. ORT now encompasses 99% of the developing world, although it is implemented unevenly, as low as 12% in Africa. 75% of ORT formula is now produced locally. By 1988 60% of the world had ORT available, and 25% of affected children received ORT. More community health workers need training in ORT, since knowledge by mothers is key to treating children. Research is needed on the effect of ORT on aspiration pneumonia, the incidence of inadequate rehydration and death after ORT. Causes of death in children with diarrhea, and organisms associated with diarrhea resistant to ORT treatment. Current research focuses on maximal flow of nutrients and solvent drag across the intercellular tight junctions of the intestinal epithelium. Short chain fatty acids, butyrate, propionate and acetate, are also being studied as adjuncts to the carbohydrates and amino acids used in ORT solutions. In the future, ORT will be used with interventions such as breastfeeding, better weaning foods, sanitation, management of persistent diarrhea caused by specific organisms, targeted therapy and immunization.

Alternatives to adolescent pregnancy: a discussion of the contraceptive literature from 1960 to 1980.

PIP: There are contraceptive methods available to the adolescent, and a knowledgeable clinician can help the patient choose the best method available for the individual. In this discussion of alternatives to adolescent pregnancy, attention is directed to the following: a historical overview of pregnancy prevention and management of sexually transmitted diseases; oral contraceptives; contraindications of oral contraceptive (OC) use (cardiovascular/cardiopulmonary conditions, migraine headaches, epilepsy, oligomenorrhea, sickle cell disease, the liver, cancer, and miscellaneous side-effects); the low-estrogen OC, the mini-pill; IUDs; barrier methods; postcoital contraceptives; injectable contraceptives; abstinence; periodic abstinence; and miscellaneous methods. Although the OC continues to be the most popular method among teenagers who use an effective method, the clinican needs to emphasize the safety and efficacy of barrier methods for the motivated teenager. The clinical also needs to remember that understanding of these issues of adolescent contraception and pregnancy is rooted in the very process of adolescence itself. The health care professional should remember that he/she is providing information for the teenage patient for only part of her reproductive years. A method selected by the patient at a particular time in her life may be replaced later by other methods as she matures. The health care professional provides the information and counsel; the patient chooses for herself.^ieng

Low birthweight and maternity care for all.

PIP: The decline in infant mortality in 1983-84 was less than the average decline the US has been experiencing since the mid-1960s, suggesting that infant mortality may be reaching a plateau. Moreover, indicators of timely provision of prenatal care decreased in 1983-84. 3 observations have been made regarding these new trends:) 1) the fact that infant mortality has been declining, albeit at a slower rate, despite relative stagnation in the rate of low birth weight infants, suggests that hospital-based intensive care is succeeding in preserving low birth weight babies; 2) the plateau in infant mortality may reflect the fact that the ability of neonatal intensive care to salvage low birth weight infants may be nearing its limit; and 3) Reagan's attack on social programs may be creating access problems that have a negative impact on infant mortality. Many feel that further reductions in neonatal mortality will be achieved only by reducing low birth weight, which accounts for 2/3 of infant mortality. Activities with potential for reducing low birth weight include: 1) risk identification, general health education, and family planning; 2) increased accessibility of early and regular prenatal care; 3) expansion of the content of prenatal care; 4) an extensive public information campaign; and 5) a multifaceted program of research on low birth weight. The Council on Maternal and Child Health of the national Association for Public Health Policy has proposed a universal maternity care program for the US aimed at assuring comprehensive prenatal and delivery care to all women and expanding the content of prenatal care to include nutrition, health education, and support services. Inadequacies in coverage for women with and without private insurance will be addressed by requiring insurrers to fully cover maternity care and offer coverage for the indigent. Such a program of universal maternity care would be a step toward a national health program.^ieng

Provision of emergency contraceptive pills to spermicide users in ghana.

This study evaluated the effect of two approaches to provision of emergency contraceptive pills (ECPs) on ECP use and unprotected intercourse among women relying on spermicides for contraception. The study enrolled 211 women at 4 family planning clinics in Ghana. At two clinics, participants were advised to return to the clinic within 3 days after unprotected intercourse to obtain ECPs. At the other two clinics, participants were given ECPs to take home for use if unprotected intercourse occurred. All participants were asked to maintain daily diaries for 8 weeks to record information on sexual activity, spermicide use, and ECP use. Women at all clinics used ECPs after at least 78% of unprotected coital acts. ECPs were used more promptly by women who had the pills at home. At three of the clinics, at most 1.3% of the coital acts were unprotected; at the fourth, 6.7% were unprotected. Our data did not suggest that the availability of ECPs increased the frequency of unprotected intercourse.

A survey of prescribing habits for high-estrogen oral contraceptives.

A simple survey was made of health-care providers to determine their attitudes toward oral contraceptives containing more than 50 mcg of estrogen. It was found that about two-thirds of respondents prescribe this group of medication, although few do so regularly. Their use seemed correlated with providers 40 years of age or older. Even members of an association of professionals interested in contraception frequently used these pills. Although this group of contraceptives is being phased out, it is felt that professionals should have ceased their use long ago.

PIP: A simple survey was made of health-care providers in the US to determine their attitudes toward oral contraceptives containing 50 mcg of estrogen. 3 groups were surveyed by mail: 100 gynecologists (2 from each state) chosen from the Directory of Fellows of the American College of Obstetricians and Gynecologists, 100 family practitioners selected from the American Academy of Family Physicians Membership Directory, and 81 members of the Association of Reproductive Health Professionals (50 gynecologists, 25 family practitioners, 6 nurse practitioners). It was found that about 2/3 (61%) of respondents prescribe this group of medication, although few do so regularly. Their use seemed correlated with providers 50 years of age or older. Even members of the association of professionals interested in contraception frequently used these pills (very few members were under 40 years of age). Although this group of contraceptives is being phased out, it is felt that professionals should have ceased their use long ago due to their high risk compared to low-estogen pills. Even though a majority of practitioners precribe high-estrogen pills, very few feel that they are essential. However, 10% responded that it would be a problem if all of these products were taken off the market.

Results of establishing medical guidelines for selecting oral contraceptive types in family planning agencies.

Family planning agencies are attempting to increase their efficiency and cost-effectiveness in delivering services, as federal funding is diminishing. We have examined the effects of establishing guidelines in a family planning agency, outlining the types of OCs to be routinely prescribed. We found that substantial savings in purchase costs were achieved, in addition to simplified inventory and distribution. These savings were accomplished with no perceptible change in patients' satisfaction. The equivalence of modern OCs in safety and effectiveness allows the creation of guidelines which are medically sound.

PIP: Family planning agencies are attempting to increase their efficiency and cost effectiveness in delivering services as federal funding is diminishing. The authors examined the effects of establishing guidelines in a family planning agency, outlining the types of oral contraceptives (OCs) which can be routinely prescribed. They found that substantial savings in purchase costs were achieved, in addition to simplified inventory and distribution. These savings were accomplished with no perceptible change in patients' satisfaction. The equivalence of modern OCs in safety and effectiveness allows the creation of guidelines which are medically sound.

Characteristics of condom use and associated problems: experience in Bangladesh.

Data from the 1983 Bangladesh Condom User Survey (BCUS) are analyzed for patterns of condom use and various problems directly influencing their effectiveness. The survey was undertaken to explain an apparent gap between reports of the number of condoms distributed in certain areas compared with prevalence of users as reported in contraceptive prevalence surveys. These data are analyzed from behavioral and management perspectives to identify various factors influencing utilization, with potential implications for understanding and improving family planning and AIDS/STD prevention service systems. Patterns of use are related to differences in source of supply through public, free or private-priced systems, differences in urban or semi-rural place of residence, and differences in perceptions of men or women. The problem with condom use most often identified by the respondents was breakage.

PIP: This study examined patterns of condom use reported in the 1983 Bangladesh Condom User Survey, stemming from a gap between high condom distribution figures and low use reported in the Contraceptive Prevalence Surveys of 1979 and 1981. In order to study populations with high enough prevalence to analyze, only certain young, urban and semi- urban, high and middle-income groups in Dhaka and surrounds were sampled. In these subjects, condoms were the most prevalent method in urban, and pills the most common method in semi-rural couples, who used condoms 4th after tubectomy and the safe period. 20% of urban, and 30% of semi-rural couples purchased their condoms, even though free supplies were available. Reasons cited were to save time, convenience, and embarrassment over accepting free condoms. 56-60% stated that they used condoms at every coitus; 14-20% said most of the time. 66-71% of urban and 22-49% of semi-rural people reported switching methods, mainly because of side effects and complications or fear of side effects. Breakage was reported by 43% of men and 30% of women, or a mean of 3-5 breaks in a 2-3 year period. Over 10% of urban women reported allergic reactions. Implications of these findings for program managers included: charge a nominal fee for condoms in many locations; teach people that condoms have no side effects; educate new users on how to avoid breakage; possible problems with shelf-life.

Selective prescribing of third generation oral contraceptives (OCs).

PIP: In France, two Paris-based physicians conducted a nationwide survey between November 30 and December 5, 1995, of 120 gynecologists (GYNs) and 262 general practitioners (GPs) to determine whether certain types of oral contraceptives (OCs) are more likely to be prescribed to women with a relative increased risk of venous thromboembolism (VTE). 88% of the GYNs and 82% of GPs prescribed combined OCs. Both types of physicians were significantly more likely to prescribe OCs containing third generation progestogens for women with a recognized risk factor of VTE, those who have never been exposed to synthetic hormones (first time OC users), and young women. They did not prescribe any OC at all for women who had developed VTE during OC use or during pregnancy. GYNs denied all women with a personal history of VTE a prescription for any OC, including third generation OCs. Based on these findings, the researchers propose that studies take into account the selectivity of OC prescription before concluding a causal relationship between the incidence of OC-induced VTE and certain types of OCs.^ieng

Growth charts and the assessment of infant feeding practices in the western world and in developing countries.

Changes during the past ten years in infant feeding practices are described and it is demonstrated that with the growing popularity of breast feeding, plus the later addition of solids, dietary energy intakes are substantially lower than they were. These dietary changes would appear to be associated with alterations in the detailed pattern of growth. When exclusively breast-fed, babies, if anything, grow more quickly than growth standard rates, but after 3-4 months a relative deceleration in growth velocity becomes apparent. The anthropometric and dietary findings are discussed in relation to the use of growth charts for the assessment of the adequacy of infant feeding practices in the western world and especially in the Third World. A reanalysis of data indicates that diet-related growth faltering probably does not occur in many developing country situations until later than would be suggested by growth standards currently in use.

PIP: Changes during the past 10 years in infant feeding practices are described and it is demonstrated that with the growing poopularity of breastfeeding plus the later addition of solids, dietary energy intakes are substantially lower than they were. These dietary changes would appear to be associated with alterations in the detailed pattern of growth. When exclusively breastfed, babies tend to grow more quickly than growth standard rates, but after 3-4 months a relative deceleration in growth velocity becomes apparent. The anthropometric and dietary findings are discussed in relation to the use of growth charts for the assessment of the adequacy of infant feeding practices in the western world and especially in the 3rd world. A reanalysis of data indicates that diet-related growth faltering probably does not occur in many developing country situations until later than would be suggested by growth standards currently in use.

The availability and cost of antibiotics for treating PID in the Central Region of Ghana and implications for compliance with national treatment guidelines.

The availability and cost of antibiotics for treating pelvic inflammatory disease (PID) were assessed in 17 drug-dispensing outlets in 5 districts of the Central Region, Ghana. The outlets included the dispensaries of 2 regional and 4 district hospitals, 4 privately-owned pharmacies and 7 chemical seller shops. The most common antibiotics available, including co-trimoxazole, metronidazole, benzylpenicillin, amoxycillin, chloramphenicol and gentamicin, were also the lowest-priced drugs. Conversely, the most expensive antibiotics including ceftriaxone, ciprofloxacin, cefuroxime and spectinomycin, were also the least commonly available. Recommended anti-gonococcal antibiotics (ciprofloxacin, ceftriaxone) may not be prescribed if they are not available in the districts.

PIP: This paper assessed the availability and cost of antibiotics used for treating pelvic inflammatory disease in 17 drug-dispensing outlets in five districts of the Central Region, Ghana. The outlets included the dispensaries of 2 regional and 4 district hospitals, 4 privately owned pharmacies, and 7 chemical seller shops. The most common antibiotics available, including cotrimoxazole, metronidazole, benzylpenicillin, amoxycillin, chloramphenicol, and gentamicin, were also the lowest priced drugs. In contrast, the most expensive antibiotics, including ceftriaxone, ciprofloxacin, cefuroxime, and spectinomycin, were also the least commonly available. Recommended anti-gonococcal antibiotics (ciprofloxacin, ceftriaxone) may not be prescribed if they are not available in the districts.

Bringing parents into school clinics: parent attitudes toward school clinics and contraception.

Prior to implementing a change in school clinic policy to allow dispensing of contraceptives, parents of school-based clinic (SBC) enrollees were surveyed regarding attitudes toward clinic quality of care, desired services, and contraceptive distribution. Telephone interviews were conducted with a systematic sample of 262 parents who normally are in charge of the adolescent's health care. Parental opinion was felt to be crucial in shaping Baltimore SBC contraception policy. Parents overwhelmingly endorsed current clinic services including family planning for sexually active teens, annual physicals, and drug and alcohol counseling. Most parents rated the SBC as excellent (25%) or very good (36%), although a substantial minority found it difficult to rate the clinics (27%, "don't know"). Parents with prior verbal contact (45%) were more likely to rate the clinic as excellent (35% versus 16%) and less likely to respond "don't know" (13% versus 38%, p less than 0.001). Parent attitudes toward contraception was context specific: 63% endorsed and 27-30% opposed prescribing and dispensing. If a boy (or girl) was already having sex, 76% (or 75%) of parents supported and 14% (or 17%) opposed providing birth control pills or condoms. With parental permission, 93% supported contraception and only 3% were opposed. No differences were found by age, race, gender, or grade of student. Prior verbal communication with the clinic did not affect parent attitudes toward contraception. Consideration of parent attitudes was critical to changing SBC contraceptive dispensing policy in Baltimore. Contraceptive distribution, after counseling and necessary medical care, was initiated in September 1990. The parent and community response has been very supportive.

PIP: Prior to implementing a change in school clinic policy concerning the dispensing of contraceptives, parents of school-based clinic (SBC) enrollees were surveyed concerning attitudes toward clinic quality of care, desired services, and contraceptive distribution. Telephone interviews were conducted with a systematic sample of 2622 parents who are normally in charge of the adolescent's health care. Parental opinion was felt to be crucial in shaping Baltimore SBC contraception policy. Parents overwhelmingly endorsed the current clinic services which included family planning for sexually active teens, annual physical, and drug and alcohol counseling. Most parents rated the SBC as excellent (25%) or very good (36%), although a substantial minority found it difficult to rate the clinics (27%; didn't know). Parents with prior verbal contact (45%) were more likely to rate the clinic as excellent (35% vs. 16%) and less likely to respond "don't know" (13% vs. 38%; p0.001). Parental attitude toward contraception was context-specific--63% endorsed and 27-30% opposed prescribing and dispensing. If a boy (or girl) was already engaging in sex, 76% (or 75%) of the parents supported and 14% (or 17%) opposed the provision of birth control pills or condoms. With parental permission, 93% supported contraception and only 3% were opposed. No differences were seen by age, race, gender, or grade of student. Prior verbal communication with the clinic did not affect parental attitudes toward contraception. consideration of parental attitudes was critical to changing SBC contraceptive dispensing policy in Baltimore. Contraceptive distribution, after counseling and necessary medical care, was initiated in September 1990. The parental and community response has been very supportive.

Family planning services at school-based health centers: findings from a national survey.

Although nearly 1000 school-based health centers (SBHCs) operate in the United States, little is known about SBHCs' sexual and reproductive health services. This study investigated reproductive and sexual health services delivery in SBHCs, specifically the types of services available in SBHCs. A 16-page, self-administered questionnaire asked center staff to identify the reproductive health services provided on site as well as which services were restricted and by whom. The results suggest that whereas most SBHCs provided at least one reproductive health service, most centers were restricted from providing contraceptive services, usually by school district policy.

Condom distribution in the schools.

PIP: The issue of condom availability has become a target for those who oppose adolescent sexual activity ad who would like to restrict adolescents' access to information and services. The author is an advocate for the legal rights of children and youth, and, as such, discusses a few issues which can support or facilitate the establishment of responsible programs to make condoms available in schools. Specifically, she discusses the ethical implications of requiring parental consent for condom availability; the legal considerations related to parental consent requirements; the need to remember that legal issues are often a smokescreen for something else; and the importance of viewing legal issues related to condom availability programs in the broader context of other legal issues related to adolescent health, teenage pregnancy, and HIV. The author concludes by positing that the answers are in strategy, not law. Any strategies to improve condom availability or improve adolescents' access to health care should, however, include finding ways to use the law to benefit youth. Moreover, where laws are concerned, one must search for the most expansive interpretations of existing laws and try to change them when they present real obstacles.^ieng

A pilot program of contraceptive continuation in six school-based clinics.

PURPOSE: Few school-based health centers (SBHC) in the United States dispense contraceptives on-site and little is known about contraceptive continuation in these health centers. METHODS: An 11-month contraceptive continuation pilot project offering monthly reproductive health assessment and counseling to students enrolled in Baltimore school clinics was evaluated. One hundred-forty-three women voluntarily enrolled in the study over a seven month period. A monthly contraceptive calendar was developed to collect data on contraceptive use, pregnancy and STD risk, sexual behavior and parental support for contraceptive use. Physical assessment was provided as needed to assess the presence of STD's or pregnancy. Data were analyzed for the month prior to enrollment in the program and eleven months after entry into the program. RESULTS: Both contraceptive (OCP) use and abstinence increased over the course of the program. Condom use remained at approximately 30% with frequent use of OCP's and condoms, condoms or abstinence. Program drop-out was common. Thirteen students became pregnant while enrolled in the program and 35% of the students were diagnosed with one or more sexually transmitted diseases. Partner-switching was common, although two or more partners within any one month was rare. CONCLUSIONS: Monthly follow-up provided through SBHCs can improve contraceptive use although dropout rate and contraceptive failure remain high.