Elsevier

Contraception

Volume 102, Issue 5, November 2020, Pages 339-345
Contraception

Evaluation of a computerized contraceptive decision aid: A randomized controlled trial,☆☆

https://doi.org/10.1016/j.contraception.2020.08.002Get rights and content

Abstract

Objective

To evaluate the effectiveness of a contraceptive decision aid in reducing decisional conflict among women seeking reversible contraception.

Study Design

We conducted a randomized trial of a computer-based decision aid compared to a control group for women presenting for reversible contraception at two clinics affiliated with an academic medical center. The primary outcome was change in decisional conflict, measured before and after the healthcare visit using the validated Decisional Conflict Scale. We hypothesized the decision aid would reduce the decisional conflict score by 10 points on a 100-point scale (0 = no conflict, 100 = high conflict) compared to the control group. Secondary outcomes included contraceptive method chosen and satisfaction with the healthcare visit.

Results

We enrolled and randomized 253 women, and 241 had complete data for our primary outcome. Overall, pre-visit decisional conflict scores were low, reflecting low levels of decisional conflict in our sample; median score 15 (range 0–80) in the decision aid and 10 (0–85) in the control group (p = 0.45). Both groups had a similar reduction in median decisional conflict after the healthcare visit: −10 (−80 to 25) and −10 (−60 to 5) in the decision aid and control groups respectively (p = 0.99). Choice of contraception (p = 0.23) and satisfaction with healthcare provider (p = 0.79) also did not differ by study group.

Conclusions

Decisional conflict around contraception was low in both groups at baseline. Use of a computerized contraceptive decision aid did not reduce decisional conflict, alter method choice, or impact satisfaction compared to the control group among women choosing reversible contraception.

Implications

Use of a computerized contraceptive decision aid did not reduce decisional conflict or alter method choice compared to the control group among women choosing reversible contraception. Future studies could focus on testing the decision aid in different clinical settings, especially where barriers to providing comprehensive contraceptive counseling exist.

Introduction

Like many health care decisions, the choice of a contraceptive method is a preference-sensitive decision. Women have multiple, sometimes competing, preferences for contraceptive method characteristics including effectiveness, frequency of use, and side effects [1], [2], [3], [4]. Method effectiveness is often cited as an important characteristic for the majority of women choosing contraception [1], [2]. However, the most effective reversible methods, intrauterine devices (IUD) and implants [5], are currently used by a minority (14.3%) of contracepting women [6]. The lower rate of IUD and implant uptake may be due to less patient desire for these methods, or reflects a lack of concordance between patient preferences and contraceptive method selected. If present, this lack of concordance may be due to inadequate patient knowledge, lack of awareness, or unclear values. A previous randomized trial of a computer-based, contraceptive tool found that women assigned to the intervention were more likely to choose an effective method of contraception compared to the control group [7].

One way to assist women in choosing contraception is through a patient decision aid. Decision aids increase knowledge, clarify personal values, and improve the match between values and healthcare choices [8]. Women making contraceptive decisions also rate computerized decision aids to be both helpful and enjoyable [7], [9], [10]. In one study, women who received a personalized print-out were more likely to continue use of their contraceptive method at 4 months [9]. Therefore, integration of a decision aid into the contraceptive decision making process may be a feasible, effective way to improve alignment between contraceptive preferences and method, which in turn may improve contraceptive use, satisfaction, and continuation.

In this study, we developed a tablet-based contraceptive decision aid designed to elicit women’s preferences for contraceptive characteristics and provide the top three reversible contraceptive recommendations that fit the woman’s preferences. We randomized participants to the decision aid or a tablet-based survey with items about general reproductive health (control group) prior to their healthcare provider visit. Our hypothesis was that women using the contraceptive decision aid would report a greater reduction in decisional conflict compared to the control group. Our secondary outcomes were to compare contraceptive method chosen and satisfaction with the healthcare provider between the randomized groups.

Section snippets

Algorithm development

We developed a tablet-based contraceptive decision aid designed to elicit individuals’ preferences about reversible contraception and provide information about options that aligned with these preferences. The decision aid contained items about past medical and reproductive history, prior contraceptive use, reproductive plans, and contraceptive preferences. Participants in the decision aid group viewed a list of 17 possible contraceptive preferences based on previous research (Appendix A) [1],

Participant characteristics

Between January and August 2014, we enrolled and randomized 253 women. Fig. 1 shows the comprehensive breakdown of recruitment and study flow. There were 167 women randomized to the contraceptive decision aid and 86 women randomized to the control group. The tablet malfunctioned for two participants (1 decision aid, 1 control group) without saving any data. We compared demographic and reproductive statistics for the 251 participants with available data. Two participants in the control group did

Discussion

In this randomized controlled trial, we found that use of a computerized contraceptive decision aid did not reduce decisional conflict among women seeking reversible contraception. Additionally, the contraceptive method chosen by the participant at the end of the visit did not differ between the two groups. Nearly 94% of women in the decision aid arm chose a contraceptive method consistent with at least one of their stated preferences.

Among our sample, baseline median decisional conflict scores

Acknowledgements

We thank Bedsider.org, a program of Power to Decide, for their assistance with programming the computerized contraceptive decision aid and sharing of digital content. We would like to thank Rachel Paul, MPH for her assistance with manuscript preparation.

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    • Effects of technology-based contraceptive decision aids: a systematic review and meta-analysis

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      The 4-month follow-up study27 showed a high continuation rate for both intervention arms, with the tailored decision aid having a higher continuation than the control group (aOR, 5.48; 95% CI, 1.72–17.42). Eight studies (N=3700)26,29,30,32–34,37,38 demonstrated statistically significantly higher contraceptive knowledge scores among decision aid users (mean difference [MD], 0.09; 95% CI, 0.05–0.13; I2=53.86%; P=.05) than control participants. Meaning, on average, decision aid users were 9 percentage points more likely to retain correct contraceptive knowledge than their control counterparts.

    Funding: This research was supported in part by: (1) the Society of Family Planning (SFP, grant numbers SFP3-1, SFP5-8) and (2) the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) (grant number K23HD070979). The funders had no role in the identification, design, conduct, and reporting on this analysis. The content is solely the responsibility of the authors and does not necessarily represent the official view of NICHD.

    ☆☆

    Conflicts of Interest: Dr. Madden serves on a data safety monitoring board for phase 4 safety studies of Bayer contraceptive products. Dr. Peipert receives research funding from Bayer Healthcare Pharmaceuticals, CooperSurgical/TEVA, and Merck & Co, Inc. and serves on an advisory board for CooperSurgical Pharmaceuticals. Dr. Politi receives research funding from Merck & Co. The other authors do not have any potential conflicts of interest to report.

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