Women's values in contraceptive choice: a systematic review of relevant attributes included in decision aids

After the pill. Young women’s contraceptive choices in the age of hormone rejection

INTRODUCTION

Although the pill is still the contraceptive method most commonly used by young women in France, since the ‘00s there has been a decline in its use and a questioning of its centrality in the contraceptive norm. This questioning is part of a growing climate of mistrust toward hormonal methods.

PURPOSE OF THE RESEARCH

Based on an analysis of a corpus of twenty-one interviews with women aged between twenty and twenty-eight on the subject of contraceptive choice, this article aims to provide information on the ways in which rejection of hormones is expressed and to determine its concrete effects on the interviewees’ contraceptive choices.

RESULTS

The survey shows the prevalence of mistrust of hormones among the young women interviewed. This mistrust is rarely rooted in their contraceptive experience; with a few exceptions, it seems to be more diffuse. This mistrust is most often expressed by women when it comes to justifying stopping the pill, the logistical burden of which becomes increasingly heavy as the years go by. However, the vast majority of women who reject the use of hormones continue to use medical contraception, including hormonal contraception, as long as it is perceived to be easier to use than the pill.

CONCLUSIONS

By questioning hormonal contraception, and the pill in particular, young women are denouncing the lack of choice: they are not asking for less contraception, but for contraception that is better suited to their needs.

The effect of cognitive-behavioral counseling on maternal-fetal attachment among pregnant women with unwanted pregnancy in Iran: A randomized clinical Trial

Background

Unwanted pregnancy is an important public health concern that can have significant health, social, and economic effects on the mother, the baby and her family. The establishment and enhancement of maternal-fetal attachment (MFA) play a role in the promotion of emotional communication between the mother and the child in the future. This study aimed at investigating the effect of cognitive-behavioral counseling on maternal-fetal attachment among pregnant women with unwanted pregnancy.

Methods

In this randomized clinical trial, 60 eligible pregnant women with unwanted pregnancy and gestational age of 22-28 weeks who had referred to health centers in Mashhad, a city in the northeast of Iran, were selected and they were through random block assignment divided into two groups of counseling with the cognitive-behavioral approach (n = 30) and the control group (n = 30). In addition to the routine pregnancy care, the cognitive-behavioral counseling group received four group counseling sessions on a weekly basis, while the control group only received the routine pregnancy care from healthcare providers. Maternal-fetal attachment before and after intervention in the two groups was assessed through Cranley's Maternal-Fetal Attachment Scale. Comparison of mean scores within and between the two groups was performed using SPSS 21 through independent and paired t-tests.

Results

At the end of the study and after the intervention, the mean scores of maternal-fetal attachment in the intervention and control groups were 94.06 ± 11.73 and 80.16 ± 10.09, respectively, and the difference between the groups was significant. Although the difference between the mean scores of each group at the beginning and the end of the study was significant, this difference between the two groups was also noticeable (21.56 ± 12.16 vs 7.40 ± 12.39) and statistically significant.

Conclusions

Cognitive-behavioral counseling can be effective in enhancing the maternal-fetal attachment in unwanted pregnancies; therefore, it is recommended to be integrated into pregnant women's healthcare programs.

Women's experiences of dealing with fertility and side effects in contraceptive decision making: a qualitative study based on women's blog posts

BACKGROUND

Worldwide, there is limited knowledge regarding women's views of future fertility in relation to contraceptive use. Few studies include material where women share their experiences at peer-written public domain websites, in spite of a larger portion of women discontinuing use of contraceptives. The objective of this study was to explore women's experiences of contraceptive methods based on data gathered from individual blog posts.

METHODS

Explorative qualitative study including 123 individual blog posts as the data source analysed with inductive thematic analysis.

RESULTS

Two themes were identified. Theme 1, 'Seeking control over reproduction and optimise fertility' including the sub-themes; Having the possibility to decide if, and when, to become pregnant, The value of effective contraceptive methods and the impact of women's sexuality, A wish to understand the body's normal fertility function and Limited knowledge-sharing information about the menstrual cycle during counselling and Theme 2, 'Making the complex decision on their own' including the sub- themes; Limited or subpar guidance in counselling and need for information from social media, Relational and environmental factors influencing contraceptive decision making and Considering beneficial effects and fears of adverse health effects when using hormonal contraceptive methods.

CONCLUSIONS

During counselling, women desired an extended dialogue regarding effectiveness, health effects of different methods and an increased understanding of their menstrual cycle. Insufficient understanding of contraceptive methods can lead to use of methods not providing the expected level of protection. Hormonal contraceptives, especially Long-acting reversible contraception (LARC) were believed to inhibit fertility long after ending treatment.

Acceptability and perceived feasibility of adapted encounter decision aids on contraceptive methods: An interview study with healthcare providers and Chinese migrant women

Objective

This study aimed to explore the perceived acceptability, usefulness, and feasibility of a suite of encounter decision aids (DAs) on contraceptive methods with Chinese migrant women living in Australia and healthcare providers.

Methods

Semi-structured in-depth interviews with 22 Chinese migrant women and twenty healthcare providers were conducted. Transcribed data were analysed using the qualitative content analysis method.

Results

Women perceived the DAs to be informative and useful. They suggested making the DAs available outside the clinical settings. Healthcare providers perceived the DAs to be comprehensive and valuable in informing women about contraceptive methods. Some providers had concerns as to the information load and the length of the DAs. Such concerns were eased when provided with an explanation of how to use the DAs. Most women and healthcare providers preferred the numerical format for side-effect probability information presentation.

Conclusion

Making the encounter DAs available in both the Chinese and English languages can be valuable in assisting Chinese migrant women in making informed decisions about contraceptive methods.

Innovation

This study is the first to evaluate the acceptability and perceived feasibility of patient decision aids with members of a migrant community in Australia. The findings highlight the need for disseminating the DAs both within and outside the clinical settings.

Developing and Testing a Chatbot to Integrate HIV Education Into Family Planning Clinic Waiting Areas in Lusaka, Zambia

BACKGROUND

To maximize protection against both unintended pregnancy and HIV, it is important that family planning (FP) services integrate HIV counseling, both to support method choice and identify potential HIV services of interest, such as pre-exposure prophylaxis (PrEP). However, FP providers often lack sufficient time and knowledge to address HIV vulnerability with clients. To potentially offload some of the initial HIV counseling burden from FP providers, we developed and tested a chatbot that provided information about HIV and dual protection to FP clients in waiting areas of FP clinics in Lusaka, Zambia.

CHATBOT DEVELOPMENT

We drafted a scripted conversation and tested it in English in formative workshops with Zambian women between the ages of 15 and 49 years. After translating the content to Bemba and Nyanja, we conducted a second round of workshops to validate the translations, before uploading the content into the chatbot platform.

CHATBOT USER TEST

Thirty volunteers tested the chatbot in 3 Lusaka FP clinics, completing an exit survey to provide feedback. A large majority (83%) said they learned new HIV information from the chatbot. Twenty (67%) learned about PrEP for the first time through the chat. Most (96%) reported discussing HIV with the provider, after engaging with the chatbot. In response to an open-ended question, several testers volunteered that they wanted to learn more about PrEP.

CONCLUSIONS

Pre-consultation waiting-area time is an underutilized opportunity to impart HIV information to FP clients, thereby preparing them to discuss their dual HIV and pregnancy prevention needs when they see their providers. FP clients expressed particular interest in learning more about PrEP, underscoring the importance of integrating HIV into FP services.

Factors influencing contraception choice and use globally: a synthesis of systematic reviews

BACKGROUND

Unintended pregnancy has a huge adverse impact on maternal, child and family health and wealth. There is an unmet need for contraception globally, with an estimated 40% of pregnancies unintended worldwide.

METHODS

We systematically searched PubMed and specialist databases for systematic reviews addressing contraceptive choice, uptake or use, published in English between 2000 and 2019. Two reviewers independently selected and appraised reports and synthesised quantitative and qualitative review findings. We mapped emergent themes to a social determinants of health framework to develop our understanding of the complexities of contraceptive choice and use.

FINDINGS

We found 24 systematic reviews of mostly moderate or high quality. Factors affecting contraception use are remarkably similar among women in very different cultures and settings globally. Use of contraception is influenced by the perceived likelihood and appeal of pregnancy, and relationship status. It is influenced by women's knowledge, beliefs, and perceptions of side effects and health risks. Male partners have a strong influence, as do peers' views and experiences, and families' expectations. Lack of education and poverty is linked with low contraception use, and social and cultural norms influence contraception and expectations of family size and timing. Contraception use also depends upon their availability, the accessibility, confidentiality and costs of health services, and attitudes, behaviour and skills of health practitioners.

INTERPRETATION

Contraception has remarkably far-reaching benefits and is highly cost-effective. However, women worldwide lack sufficient knowledge, capability and opportunity to make reproductive choices, and health care systems often fail to provide access and informed choice.

Preferences for Multipurpose Technology and Non-oral Methods of Antiretroviral Therapy Among Women Living With HIV in Western Kenya: A Survey Study

Introduction

Understanding interests in and preferences for multipurpose technology (MPT) for the co-administration of contraception and antiretroviral therapy (ART) and alternative, non-oral ART methods among women living with HIV (WLHIV) is vital to successful implementation of future treatment options, such as long-acting injectable ART.

Methods

Between May 2016 and March 2017 we conducted a cross-sectional telephone survey of 1,132 WLHIV of reproductive potential with prior experience using intermediate- or long-acting contraceptive methods in western Kenya. We present descriptive statistics and multinomial logistic regression to evaluate predictors of interest in specific MPT and non-oral ART methods.

Results

Two-thirds (67%) reported interest in MPT, with the most common reason for interest being ease of using a single medication for both purposes of HIV treatment and pregnancy prevention (26%). Main reasons for lack of interest in MPT were need to stop/not use contraception while continuing ART (21%) and risk of side effects (16%). Important characteristics of MPT were effectiveness for pregnancy prevention (26%) and HIV treatment (24%) and less than daily dosing (19%). Important characteristics of non-oral ART methods were less than daily dosing (47%), saving time accessing ART (16%), and effectiveness of HIV treatment (15%). The leading preferred methods for both MPT and non-oral ART were injectables (50 and 54%) and implants (32 and 31%). Prior use of a contraceptive implant or injectable predicted interest in similar methods for both MPT and non-oral ART methods, while this relationship did not appear to vary between younger vs. older WLHIV.

Discussion

Most WLHIV in western Kenya are interested in MPT for HIV treatment and contraception. Prior exposure to contraceptive implants or injectables appears to predict interest in similar methods of MPT and non-oral ART. Developers of MPT and non-oral ART methods should strongly consider WLHIV's preferences, including their changing reproductive desires.

Developing an Assessment of Contraceptive Preferences in Botswana: Piloting a Novel Approach Using Best-Worst Scaling of Attributes

Introduction

To develop an attribute-based method for assessing patient contraceptive preferences in Botswana and pilot its use to explore the relationship between patient contraceptive preferences and the contraceptive methods provided or recommended to patients by clinicians.

Methods

A list of contraceptive attributes was developed with input from patients, clinicians, and other stakeholders. We assessed patient preferences for attributes of contraceptives using a discrete choice "best-worst scaling" approach and a multi-attribute decision-making method that linked patient attribute preferences to actual contraceptive method characteristics. Attribute-based patient method preferences and clinician recommendations were compared in 100 women seeking contraceptive services, and 19 clinicians who provided their care. For 41 of the patients, the short-term reliability of their preference scores was also examined.

Results

For 57 patients who wanted more children in the future, the degree of concordance between patients and clinicians was 7% when comparing the top attribute-based contraceptive preference for each woman with the clinician-provided/recommended method. When the top two model-based preferred contraceptive methods were considered, concordance was 28%. For 43 women who did not want more children, concordance was 0% when using the patient's model-based "most-preferred" method, and 14% when considering the top two methods. Assessment of the short-term reliability of preference scores yielded an intraclass correlation coefficient of 0.93.

Conclusions

A best-worst scaling assessment of attributes of contraceptives was designed and piloted in Botswana as a Contraceptive Preference Assessment Tool. The preference assessment was found to have high short-term reliability, which supports its potential use as a measurement tool. There was very low concordance between women's attribute-based contraceptive preferences and their clinician's provision/recommendations of contraceptive methods. Using such a preference assessment tool could encourage greater patient involvement and more tailored discussion in contraceptive consultations.

'Most women really actually do just appreciate being asked': clinicians' views on integrating sexual wellbeing into contraceptive care

A growing body of literature suggests that contraceptives' impact on sexual experiences influences willingness to initiate and continue with a method. Little is known, however, about how clinicians engage with clients on this topic during contraceptive consultations. Fifteen clinicians in South Eastern Australia participated in semi-structured interviews between April and June 2019. Interviews were analysed using inductive, semantic thematic analysis. Participants varied in their evaluation and management of contraceptives' sexual side effects and the legitimacy given to women's bodily experience versus their own understanding of the evidence in the medical literature. We identified two distinct groups of clinicians: those who prioritised sexual wellbeing as a primary issue in contraceptive consultations and those who perceived sexual wellbeing as a secondary concern. The difference in practices was influenced by whether participants considered sexual wellbeing to be part of holistic care provision and their views on the clinician's role in raising the topic. Strategies to equip clinicians to integrate sexual wellbeing into contraceptive consultations include interactive clinical training and incorporating information about sexual side effects into contraceptive guidelines and client resources. Benefits gained from normalising sexual wellbeing could extend beyond contraceptive care to help clinicians address clients' sexual wellbeing in other contexts.

Effectiveness of Contraceptive Decision Aids in Adolescents and Young Adults: A Systematic Review

BACKGROUND

Contraceptive decision aids may support adolescents and young adults (AYA) in choosing contraceptive methods that fit their unique reproductive health needs.

OBJECTIVE

To provide a systematic review of studies examining the effectiveness of contraceptive decision aids in AYA.

MATERIALS AND METHODS

A systematic search was conducted of studies published between January 1, 2011, and March 31, 2021 using PubMed, Cochrane, and ClinicalTrials.gov. Studies were included if a contraceptive decision aid (ie, paper handout, mobile application, website, or video) was evaluated in AYA populations (age ≤30 years) in the United States. The primary outcome was decision aid effectiveness (ie, change in contraceptive knowledge, interest in contraception, contraceptive use, unintended pregnancies, and satisfaction with the decision aid).

RESULTS

Seven randomized controlled trials and 3 pre-post studies, reporting on 3725 AYA (range, 11-30 years), met inclusion criteria. No studies were excluded due to risk of bias. The methodologies and results were heterogeneous, but most consistently demonstrated increased contraceptive knowledge.

CONCLUSION

Ten studies evaluated a range of contraceptive decision aid formats for AYA. Decision aids appear to be effective at increasing contraceptive knowledge temporarily, but their effect on other contraceptive outcomes is unclear. Future research should evaluate decision aids specifically in adolescents.

Leveraging the Client-Provider Interaction to Address Contraceptive Discontinuation: A Scoping Review of the Evidence That Links Them

Despite considerable investment and effort, unmet need for contraception remains an obstacle to improved family planning outcomes. One influencing factor is the frequency of contraceptive discontinuation among users who desire to prevent pregnancy, often due to method-related concerns and side effects. Contraceptive users have the right to be supported during counseling to voluntarily choose methods that align with their individual needs and preferences. Contraceptive counseling, as a key component of quality of care, is particularly important for providers to reduce unmet need among their clients. This scoping review examined the state of the evidence on contraceptive counseling and its impact on discontinuation. The review first examines the association between quality of care and contraceptive discontinuation, then looks to what the current body of evidence suggests are women's contraceptive counseling priorities, and lastly, explores whether specific counseling tools and approaches have been evaluated with discontinuation as an outcome. The results identified general principles and priorities for good counseling including person-centeredness, client-tailored information exchange, clear and concise information on side effects and bleeding changes, reducing providers' implicit and explicit biases, and trust and respect between the client and provider. The review of the literature also found that evidence to support the use of specific counseling tools and approaches to reduce contraceptive discontinuation is insufficient; research should be designed to determine which specific elements of the client-provider interaction can be improved to significantly impact contraceptive discontinuation. This evidence could inform how the global community of practice might improve and leverage specific counseling approaches and tools to address the most common predictors of discontinuation.

What's Known and What's Next: Contraceptive Counseling and Support for Adolescents and Young Adult Women

The low rates of actual contraceptive failure and high rates of contraceptive use among young women highlight that choice of contraceptive method and patterns of contraceptive use greatly influence unintended pregnancy risk. Promoting contraceptive use among adolescent and young adult women requires supportive health systems and health providers who understand this population's evolving developmental needs. It also requires an awareness of effective tools for counseling patients, while being mindful of the power dynamics operational during clinical encounters to avoid inadvertently coercive interpersonal dynamics. Missed opportunities to provide such patient-centered care can lead to unplanned pregnancies and suboptimal health and social consequences for young women. Unfortunately, health providers often lack the tools and resources to appropriately identify and meet individual young women's contraceptive needs. This article summarizes the evidence supporting contraceptive counseling strategies linked with contraceptive initiation among young women, and evidence-based approaches for supporting contraceptive adherence and continuation after method initiation. It also orients readers to the unique neurodevelopmental factors that influence the shared decision-making process during contraception counseling sessions with young women. New and emerging approaches for supporting contraceptive initiation, adherence, and continuation are reviewed.

Reasons for rejecting hormonal contraception in Western countries: A systematic review

Over the past decade, women in Western countries have taken to various social media platforms to share their dissatisfactory experiences with hormonal contraception, which may be pills, patches, rings, injectables, implants or hormonal intrauterine devices (IUDs). These online testimonials have been denounced as spreading "hormonophobia", i.e. an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception. In order to move toward a reproductive justice framework, we propose to study the arguments that women and men (as partners of female users) recently put forward against hormonal contraception to see whether they are related to hormonophobia. The aim of this article is to conduct a systematic review of the recent scientific literature in order to construct an evidence-based typology of reasons for rejecting hormonal contraception, in a continuum perspective from complaints to choosing not to use it, cited by women and men in Western countries in a recent time. The published literature was systematically searched using PubMed and the database from the French National Institute for Demographic Studies (Ined). A total of 42 articles were included for full-text analysis. Eight main categories emerged as reasons for rejecting hormonal contraception: problems related to physical side effects; altered mental health; negative impact on sexuality; concerns about future fertility; invocation of nature; concerns about menstruation; fears and anxiety; and the delegitimization of the side effects of hormonal contraceptives. Thus, arguments against hormonal contraception appeared complex and multifactorial. Future research should examine the provider-patient relationship, the gender bias of hormonal contraception and demands for naturalness in order to understand how birth control could better meet the needs and expectations of women and men in Western countries today.

Contraceptive and abortion practices of young Ghanaian women aged 15-24: evidence from a nationally representative survey

Background

Young Ghanaian women experience high rates of unmet need for contraception and unintended pregnancy, and face unique barriers to accessing sexual and reproductive health services. This study provides a comprehensive national analysis of young women’s contraceptive and abortion practices and needs.

Methods

In 2018, we conducted a nationally representative survey of women aged 15–49, including 1039 women aged 15–24. We used descriptive statistics, multivariable logistic and multinomial regression to compare young versus older (25–49 year-old) women’s preferred contraceptive attributes, reasons for discontinuing contraception, quality of counseling, use of Primolut N-tablet, method choice correlates, and friends’ and partners’ influence. We also examined youth’s self-reported abortion incidence, abortion methods, post-abortion care, and barriers to safe abortion.

Results

Among Ghanaian 15–24 year-olds who had ever had sex, one-third (32%) were using contraception. Compared to older women, they had higher desires to avoid pregnancy, lower ever use of contraception, more intermittent sexual activity, and were more likely to report pregnancies as unintended and to have recently ended a pregnancy. Young contraceptors most commonly used condoms (22%), injectables (21%), withdrawal (20%) or implants (20%); and were more likely than older women to use condoms, withdrawal, emergency contraception, and N-tablet. They valued methods for effectiveness (70%), no risk of harming health (31%) nor future fertility (26%), ease of use (20%), and no effect on menstruation (19%). Infrequent sex accounted for over half of youth contraceptive discontinuation. Relative to older women, young women’s social networks were more influential on contraceptive use. The annual self-reported abortion rate among young women was 30 per thousand. Over half of young women used abortion methods obtained from non-formal providers. Among the third of young women who experienced abortion complications, 40% did not access treatment.

Conclusions

Young people’s intermittent sexual activity, desire for methods that do not harm their health, access barriers and provider bias, likely contribute to their greater use of coital-dependent methods. Providers should be equipped to provide confidential, non-discriminatory counseling addressing concerns about infertility, side effects and alternative methods. Use of social networks can be leveraged to educate around issues like safe abortion and correct use of N-tablet.

Young Ghanaian women can experience difficulties accessing sexual and reproductive health services, and many are not using contraception despite wanting to avoid pregnancy. To better understand their needs, we describe their preferences and behaviors around contraception and abortion. We surveyed a nationally representative sample of women aged 15–49, and compared young (15–24) versus older (25–49) women’s contraceptive preferences, reasons for stopping contraception, quality of counseling, friends’ and partners’ influence on contraceptive use, and use of abortion. One-third of 15–24 year-olds who ever had sex were using contraception. Compared to older women, young women’s pregnancies were more likely to be unintended and to end in abortion. Young women most commonly used condoms, injectables, withdrawal or implants; and were more likely than older women to use condoms, withdrawal, emergency contraception, and Primolut N-tablet. They preferred methods that were effective, did not harm their health or future fertility, were easy to use, and did not disrupt their menstrual cycle. Over half of young women who stopped contraception did so because they were not having sex regularly. Friends had more influence on contraceptive use among young women than older women. Each year on average, there were 30 abortions per 1000 young women. Over half of young women who had abortions used methods from non-formal providers, and 40% of those who had complications did not get treated. Providers should be equipped to provide confidential, non-discriminatory counseling about contraceptive side effects and options. Social networks can be used to educate women about safe abortion.

Digital Medical Device Companion (MyIUS) for New Users of Intrauterine Systems: App Development Study

Background

Women choosing a levonorgestrel-releasing intrauterine system may experience changes in their menstrual bleeding pattern during the first months following placement.

Objective

Although health care professionals (HCPs) can provide counseling, no method of providing individualized information on the expected bleeding pattern or continued support is currently available for women experiencing postplacement bleeding changes. We aim to develop a mobile phone–based medical app (MyIUS) to meet this need and provide a digital companion to women after the placement of the intrauterine system.

Methods

The MyIUS app is classified as a medical device and uses an artificial intelligence–based bleeding pattern prediction algorithm to estimate a woman’s future bleeding pattern in terms of intensity and regularity. We developed the app with the help of a multidisciplinary team by using a robust and high-quality design process in the context of a constantly evolving regulatory landscape. The development framework consisted of a phased approach including ideation, feasibility and concept finalization, product development, and product deployment or localization stages.

Results

The MyIUS app was considered useful by HCPs and easy to use by women who were consulted during the development process. Following the launch of the sustainable app in selected pilot countries, performance metrics will be gathered to facilitate further technical and feature updates and enhancements. A real-world performance study will also be conducted to allow us to upgrade the app in accordance with the new European Commission Medical Device legislation and to validate the bleeding pattern prediction algorithm in a real-world setting.

Conclusions

By providing a meaningful estimation of bleeding patterns and allowing an individualized approach to counseling and discussions about contraceptive method choice, the MyIUS app offers a useful tool that may benefit both women and HCPs. Further work is needed to validate the performance of the prediction algorithm and MyIUS app in a real-world setting.

Knowledge, attitudes and contraceptive use among Muslim Bedouin women in southern Israel

The Bedouin community in southern Israel is an authentic Muslim population that lives in close proximity to the Jewish population and is covered by the same healthcare services. The main aim of the study was to assess the attitudes, knowledge and practice of contraception among Bedouin women of childbearing age in southern Israel. Additional aims were to compare the attitudes and knowledge among women who did and did not use contraceptives and between younger and older women. A questionnaire-based cross-sectional study was carried out. The study population was comprised of women who visit a primary care clinic in the Bedouin village for any reason. It numbered 270 women with a mean age of 33.2 ± 6.6 years. The mean number of children was 5.0 ± 2.7, 27% were in polygamous marriages and 69% were married to relatives. The most recognized methods of contraception were pills and intrauterine devices (37.7%, each). Fourteen per cent of the women practiced the withdrawal method and 9% used breastfeeding for that purpose. The most common sources of knowledge on contraception were family (62% among uses and 69% among non-users), the media (58% and 50%, respectively) and healthcare providers (25% and 34%, respectively). The most common reasons for not practicing contraception were a desire to become pregnant (59%), fear of adverse effects (44%) and husband's opposition (28%). The desire to become pregnant is the main reason for not practicing contraception among women in the Bedouin community in the Negev. Participation of the husband in counselling, involvement of religious leaders can improve family planning. Education on the low rate of adverse effects and on the many health benefits of contraception can also improve adherence to the practice of contraception.

Method-specific beliefs and subsequent contraceptive method choice: Results from a longitudinal study in urban and rural Kenya

Introduction

Evidence from sub-Saharan Africa, including Kenya, shows that negative beliefs about contraceptive methods are associated with non-use. However, little is known about the relationship between contraceptive beliefs and subsequent method choice.

Methodology

We used data from a two-year longitudinal survey of married women aged 15–39 years at enrollment from one urban site (Nairobi) and one rural site (Homa Bay) in Kenya. Analysis entails descriptive statistics and estimation of a conditional logit analysis to examine associations between method-specific beliefs and choice of injectables, implants or pills among women who were not using any method or were pregnant at baseline (round 1) but adopted these methods at 12-month follow-up (Nairobi, n = 221; Homa Bay n = 197).

Results

Beliefs about pills, injectables and implants among non-users were generally negative. With the partial exception of the pill in Nairobi, the majority thought that each method was likely to cause serious health problems, unpleasant side effects, menstrual disruption, and would be unsafe for long-term use. In both sites, satisfied past use of a method and the perception that a method is easy to use had a major influence on method choice. Concerns about menstrual disruption and safety for long-term use were unimportant in both sites. There were some marked differences between the two sites. Beliefs about long-term fertility impairment and perceived husband approval had strong influences on choice of injectables, implants or pills in the urban site but not in the rural site.

Conclusion

The relative importance of beliefs, some erroneous, in predisposing women to choose one method over another appears to be conditioned by the social context. There is need for family planning counseling programmes to pay attention to erroneous beliefs and misconceptions about contraceptives.

Hormonal contraceptive use in Ghana: The role of method attributes and side effects in method choice and continuation

OBJECTIVE

To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy.

STUDY DESIGN

We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation.

RESULTS

Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided.

CONCLUSIONS

Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and long-term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate.

IMPLICATIONS

Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.

Investigating College Women's Contraceptive Choices and Sexuality

Objective This study examined the link between sexuality and contraceptive choices among college women after controlling for their relationship status. Additionally, the relationship between responsibility for contraception and women's contraceptive choices was investigated. Method: Online self-report surveys of sexuality and contraception were collected from 455 college women in the United States. Results: Women mostly preferred dual-method contraception. Sexual esteem and sexual depression predicted women's contraceptive choices. Finally, having personal or shared responsibility for contraception predicted women's contraceptive choices. Conclusion: Our findings suggest that women's psychological well-being empowers them to make contraceptive choices that allow them to experience sexuality in healthy ways.

Decision aids to prepare patients for shared decision making: Two randomized controlled experiments on the impact of awareness of preference-sensitivity and personal motives

Objective

To participate in shared decision making (SDM), patients need to understand their options and develop trust in their own decision‐making abilities. Two experiments investigated the potential of decision aids (DAs) in preparing patients for SDM by raising awareness of preference‐sensitivity (Study 1) and showing possible personal motives for decision making (Study 2) in addition to providing information about the treatment options.

Methods

Participants (Study 1: N = 117; Study 2: N = 217) were put into two scenarios (Study 1: cruciate ligament rupture; Study 2: contraception), watched a consultation video and were randomized into one of three groups where they received additional information in the form of (a) narrative patient testimonials; (b) non‐narrative decision strategies; and (c) an unrelated text (control group).

Results

Participants who viewed the patient testimonials or decision strategies felt better prepared for a decision (Study 1: P < .001, ηP2 = 0.43; Study 2: P < .001, ηP2 = 0.57) and evaluated the decision‐making process more positively (Study 2: P < .001, ηP2 = 0.13) than participants in the control condition. Decision certainty (Study 1: P < .001, ηP2 = 0.05) and satisfaction (Study 1: P < .001, ηP2 = 0.11; Study 2: P = .003, d = 0.29) were higher across all conditions after watching the consultation video, and certainty and satisfaction were lower in the control condition (Study 2: P < .001, ηP2 = 0.05).

Discussion

Decision aids that explain preference‐sensitivity and personal motives can be beneficial for improving people's feelings of being prepared and their perception of the decision‐making process. To reach decision certainty and satisfaction, being well informed of one's options is particularly relevant. We discuss the implications of our findings for future research and the design of DAs.

Best Practices for Counseling Adolescents about the Etonogestrel Implant

Among young persons, ease of use, high efficacy, and high acceptability makes the etonogestrel contraceptive implant an important choice for this age group. Adolescent-friendly, patient-centered counseling considers the patient's cognitive development, the influence of friends and family, as well as their own preferences and values. Age-appropriate language, graphics, and models are useful to explain contraceptive options and relevant side effects. Effectiveness, reversibility, safety, noncontraceptive benefits, and side effects are important attributes and should be discussed when teens are choosing a contraceptive method. In this review we describe suggested best practices for counseling adolescents about the etonogestrel implant so they can make informed, prudent decisions about using this contraceptive method.

Contraceptive Behaviors in Polish Women Aged 18-35-a Cross-Sectional Study

The aim was to evaluate contraceptive behaviors, and factors affecting them, in the population of Polish-speaking women. A cross-sectional study was performed on 6763 women, current contraceptive users, aged 18 to 35. An anonymous and voluntary questionnaire written in Polish, containing 33 questions, was distributed online from January to February 2017. The Internet and doctors were the most popular sources of information about contraception (82% and 73%, respectively). Upon choosing contraception, women paid the most attention to its efficacy (85%) and its impact on health (59%). The most common methods were combined oral contraceptives (38%) and condoms (24%). In total, 51% had chosen hormonal contraception, of which 68% experienced side effects. The most frequent were decreased libido (39%) and weight gain (22%). Factors associated with the usage of hormonal or non-hormonal contraception were: education, relationship status, parenthood, number of sexual partners, frequency of intercourses, sources of information about contraception, and factors considered most important when choosing a contraceptive method. The choice between short-acting and long-acting reversible contraception was influenced by age, relationship status, parenthood, smoking, sources of information about contraception, and factors considered most important when choosing a contraceptive method. Wide access to contraception, high-quality education, and counselling should become priorities in family planning healthcare.

Promoting or Undermining Quality Decision Making? A Qualitative Content Analysis of Patient Decision Aids Comparing Surgical and Medication Abortion

OBJECTIVES

To understand, describe, and compare the content of patient decision aids on surgical and medication abortion, including 1) attributes used to describe each method, 2) approaches to clarify patients' values, 3) language used to describe each method, and 4) language used to frame women's decision-making role.

STUDY DESIGN

We analyzed 49 decision aids identified through a previous systematic review and environmental scan. We used summative content analysis for objectives 1 and 2 and directed content analysis for objectives 3 and 4.

RESULTS

We identified 37 method attributes. Overall, the attributes privileged medical over practical and emotional information. One decision aid included an explicit values clarification approach, and others included implicit approaches, which varied in length, information consistency, and organization. We identified four themes-information consistency, subjective claims, emotive or ambiguous descriptions, and medication abortion as not a real abortion-related to the methods' descriptions. We identified three themes-agency in choice, unclear emphasis on women's preferences, and endorsement of clinic services-related to women's decision-making role. Of the nine tools that listed factors influencing women's decision making, patient preferences was often listed last.

CONCLUSIONS

Early abortion method decision aids presented a broad range of information and typically framed the method choice as the woman's. However, their emphasis on medical attributes, use of inconsistent information, and, at times, biased presentation of methods may undermine quality decision making. We recommend adapting an existing decision aid or designing a novel tool based on the content and language that women find most acceptable.

End-user involvement in developing and field testing an online contraceptive decision aid

OBJECTIVES

Decision aids in the field of healthcare contribute to informed decision making. To increase the usefulness and effectiveness of decision aids, it is important to involve end-users in the development of these tools. This article reports on the development of an online contraceptive decision aid.

METHODS

An exploratory, qualitative study was conducted in the Netherlands between 2014 and 2016. The development process of the decision aid consisted of six steps and included a needs assessment and field test. Interviews were conducted with 17 female students.

RESULTS

The needs assessment provided information on the preferred content and structure of a contraceptive decision aid and guided the development of the online contraceptive decision aid prototype. Participants had an overall positive impression of the decision aid prototype during the field test. Minor revisions were made based on participants' feedback. Participants expected that the decision aid would positively contribute to decision making by increasing knowledge and awareness regarding the available contraceptive methods and their features and attributes, and by opening up to other options than the known methods.

CONCLUSION

The developed contraceptive decision aid can contribute to better informed decision making and consultation preparation. Involving end-users in development seems valuable to adapt decision aids to specific needs and to identify in what way a decision aid influences decision making.

[The contraception consultation: CNGOF Contraception Guidelines]

OBJECTIVE

Determine the most accurate information to give to women, the most efficient way of doing it, the physical examination during a contraceptive visit and the most appropriate follow-up.

METHODS

A systematic review of French-speaking or English-speaking evidence-based literature about contraception and its visit was performed using Pubmed, Cochrane and international recommendations.

RESULTS

Showing a contraceptive preference decreases women's satisfaction (EL1) and may decrease contraceptive persistence (EL4). A GATHER's like structured consultation is recommended (Grade A). It allows a contraceptive choice improvement (EL2). Contraceptive knowledge improvement associated with a structured consultation allows a decrease in unplanned pregnancies (EL1) compared to a traditional non-personalized consultation. The main expectations of women are slightly different from what is expected by practitioners (EL2). The main topics to be addressed are efficiency, risks, cost, duration of action and practicality (EL2). The quality of interpersonal communication could allow greater contraceptive persistence (EL2). A careful behavior at the beginning of the consultation and facilitating the expression of the woman's point of view could increase the persistence of the initially prescribed contraception (EL2). Explaining the chosen contraception's adverse effect is recommended because it could allow a better persistence (Grade B). Decision aids has shown interest in the therapeutic choice (EL1). Computerized modules or slide shows in the waiting room before consultation could make the contraceptive choice easier (EL2). The presentation of contraception by effectiveness categories is better than pregnancy numbers for comparing the methods (EL1). Performing a blood pressure measurement prior to an estroprogestative contraception prescription is recommended (Grade C). In women without risk factors, literature data do not allow specific recommendations regarding breast, pelvic examination, laboratory screening and follow-up (Professional agreement).

Method-Specific Attributes that Influence Choice of Future Contraception Among Married Women in Nairobi's Informal Settlements

Despite an extensive evidence base on contraceptive method choice, it remains uncertain which factors are most influential in predisposing women toward certain methods and against others. This paper addresses this gap in knowledge by making use of rarely‐measured perceptions about specific methods, perceived social network experience of methods, and women's own past experiences using specific methods. We draw on baseline data from the project, “Improving Measurement of Unintended Pregnancy and Unmet Need for Family Planning.” Using conditional logit analysis, we ascertain which perceived method‐specific attributes, including past experience of methods by women themselves and by their friends, predict preferred future contraceptive method among 317 women living in Nairobi slums who are using no method but intend to start in the next 12 months. Results show that satisfaction with past use, positive experience of use by a woman's social network, husband/partner's approval, lack of interference with menses, and perception of safety for long term use were all associated with choice of a future method.

Regional Variations of Fertility Control Behavior among Rural Reproductive Women in Bangladesh: A Hierarchical Analysis

Women's fertility decision is quite difficult in male-dominant rural culture due to their poor reproductive autonomy. A cross-sectional survey was conducted in rural community of Bangladesh between November 2017 and February 2018 among 1285 respondents selected by multi-stage stratified sampling to explore regional variations of rural women's fertility control behavior and its determinants using hierarchical and other inferential statistics. Data collection was done by face-to-face interview using questionnaire. Average parity was 2.5 per woman and 41% respondents had three or more children. About 60% of them used modern contraceptives (MCs) and oral contraceptive pill (OCP) was their first choice. Male participation in contraceptive use was less than 5%. Regional variation, women's empowerment, fertility control knowledge, family planning (FP) attitude, social influence, perceived behavioral control (PBC) and fertility intention were significant predictors of fertility control behavior (p < 0.05). Significant regional variations were determined in fertility control behavior of rural women (p < 0.05). Almost all of its predictors explained by Theory of Planned Behavior (TPB) also showed significant regional variations (p < 0.05). Current fertility control policy should be strengthened more not only to improve fertility behavior of rural women but also to establish regional equity in fertility control by improving their reproductive decision-making in a rational way.

To switch or not to switch: Intentions to switch to injectable PrEP among gay and bisexual men with at least twelve months oral PrEP experience

BACKGROUND

Phase III trials of long-acting injectable (LAI) PrEP, currently underway, have great potential for expanding the menu of HIV prevention options. Imagining a future in which multiple PrEP modalities are available to potential users of biomedical HIV prevention, we investigated which factors might help direct a patient-physician shared-decision making process to optimize the choice of biomedical HIV prevention method.

METHODS

Participants (n = 105; ages 19-63; 46.7% men of color) were former participants in a PrEP demonstration project and had taken daily oral PrEP for ≥ 12 months. Participants were given information about LAI PrEP and asked whether they would be interested in switching from oral to LAI PrEP. Participants were also asked about specific pros/cons of LAI PrEP, PrEP attitudes and experiences, and personality factors.

RESULTS

Two-thirds (66.7%) of current oral PrEP users would switch to LAI PrEP. Intention to switch was associated with product-level and psychosocial factors. Attitudes towards logistical factors (i.e. getting to regular clinic visits for recurring shots) featured more prominently than factors related to the physical experience of PrEP modality (i.e., concerns about injection pain) as motivators for switching. In a multivariate regression model, psychosocial factors including the emotional burden of daily pill taking, deriving a sense of responsibility from PrEP use, and self-identifying as an early adopter, were the strongest predictors of switching.

CONCLUSIONS

These data underscore the importance of attending not only to product-level factors, but also to the logistical and psychological experience of prevention methods for users. Findings have significant implications for the development of patient education materials and patient-provider shared decision aids.

Hybrid Masculinity and Young Men's Circumscribed Engagement in Contraceptive Management

This research explores how gender shapes contraceptive management through in-depth interviews with 40 men and women of color ages 15 to 24, a life stage when the risk of unintended pregnancy is high in the United States. Although past research focuses on men's contraception-avoidant behaviors, little sociological work has explored ways men engage in contraception outside of condoms, such as contraceptive pills. Research often highlights how women manage these methods alone. Our research identifies how young men of color do help manage these methods through their engagement in contraceptive decision-making and use. Men accomplish this without limiting their partners' ability to prevent pregnancy. This is despite structural barriers such as poverty and gang-related violence that disproportionately affect low-income young men of color and often shape their reproductive goals. However, men's engagement is still circumscribed so that women take on a disproportionate burden of pregnancy prevention, reifying gender boundaries. We identify this as a form of hybrid masculinity, because men's behaviors are seemingly egalitarian but also sustain women's individualized risk of unintended pregnancy. This research points to the complexity of how race, class, and gender intersect to create an engaged but limited place for men in contraceptive management among marginalized youth.

Women's attitudes and beliefs towards specific contraceptive methods in Bangladesh and Kenya

BACKGROUND

Missing from the huge literature on women's attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants).

METHODS

In each site, 2424 to 2812 married women aged 15-39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study.

RESULTS

While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower.

CONCLUSIONS

High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study

BACKGROUND

Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling.

OBJECTIVE

The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool.

METHODS

This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention.

RESULTS

We are currently enrolling practices and anticipate study completion in 15 months.

CONCLUSIONS

This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

Exploring young women's decisional needs for contraceptive method choice: a qualitative study

OBJECTIVE

Assisting women with choosing contraceptive methods that meet their needs and preferences is essential to providing patient-centered care, but research to inform interventions supporting method choice is lacking. An assessment of patient decisional needs for contraceptive method choice may provide insight into patient-centered ways to support decision making.

STUDY DESIGN

Using the Ottawa Decision Support Framework as a guide, we conducted a qualitative study with semistructured interviews to identify women's decisional needs for choosing a contraceptive method. The sample consisted of 21 women aged 18-29 from an integrated health care delivery system. We employed thematic analysis to identify common themes in the participants' experience.

RESULTS

Overall, participants perceived choosing a contraceptive method to be a somewhat difficult decision and described feeling hesitant and unsure. Lack of knowledge of and familiarity with methods and the unpredictability of side effects contributed to participants' hesitancy. Women considered method choice in the context of their lives and their values for various contraceptive attributes, particularly side effects. Participants identified several sources for contraceptive information. Information from friends and family was highly influential. Participants desired both factual and experiential information.

CONCLUSIONS

Contraceptive method choice may be difficult for many young women, suggesting a need for decision support. Interventions supporting method choice may be more relevant if they directly address knowledge gaps and uncertainty as well as provide both factual and experiential information on a comprehensive set of contraceptive attributes.

Development and conceptual validation of a questionnaire to help contraceptive choice: CHLOE (Contraception: HeLping for wOmen's choicE)

OBJECTIVE

The aim of this research was to develop a questionnaire to facilitate choice of the most appropriate contraceptive method for individual women.

METHODS

A literature review was conducted to identify key aspects influencing contraceptive choice and inform development of a questionnaire for online completion. Questionnaire development was overseen by a steering committee consisting of eight gynaecologists from across Europe. The initial draft underwent conceptual validation through cognitive debriefing interviews with six native English-speaking women. A qualitative content analysis was conducted to accurately identify potential issues and areas for questionnaire improvement. A revised version of the questionnaire then underwent face-to-face and online evaluation by 115 international gynaecologists/obstetricians with expertise in contraception, prior to development of a final version.

RESULTS

The final conceptually validated Contraception: HeLping for wOmen's choicE (CHLOE) questionnaire takes ≤10 min to complete and includes three sections to elicit general information about the individual, the health conditions that might influence contraceptive choice, and the woman's needs and preferences that might influence contraceptive choice. The questionnaire captures the core aspects of personalisation, efficacy and safety, identified as key attributes influencing contraceptive choice, and consists of 24 closed-ended questions for online completion prior to a health care provider (HCP) consultation. The HCP receives a summary of the responses.

CONCLUSION

The CHLOE questionnaire has been developed to help women choose the contraception that best suits their needs and situation while optimising the HCP's time.

Development and field testing of a decision support tool to facilitate shared decision making in contraceptive counseling

OBJECTIVE

We developed and formatively evaluated a tablet-based decision support tool for use by women prior to a contraceptive counseling visit to help them engage in shared decision making regarding method selection.

METHODS

Drawing upon formative work around women's preferences for contraceptive counseling and conceptual understanding of health care decision making, we iteratively developed a storyboard and then digital prototypes, based on best practices for decision support tool development. Pilot testing using both quantitative and qualitative data and cognitive testing was conducted. We obtained feedback from patient and provider advisory groups throughout the development process.

RESULTS

Ninety-six percent of women who used the tool in pilot testing reported that it helped them choose a method, and qualitative interviews indicated acceptability of the tool's content and presentation. Compared to the control group, women who used the tool demonstrated trends toward increased likelihood of complete satisfaction with their method. Participant responses to cognitive testing were used in tool refinement.

CONCLUSION

Our decision support tool appears acceptable to women in the family planning setting.

PRACTICE IMPLICATIONS

Formative evaluation of the tool supports its utility among patients making contraceptive decisions, which can be further evaluated in a randomized controlled trial.

Patient perceptions of a decision support tool to assist with young women's contraceptive choice

OBJECTIVE

Contraceptive decision support tools (DSTs) have been suggested as a way to provide patient-centered contraceptive care, but little is known about the role they play in women's decision-making. The aim of this study is to understand patients' perceptions of the value of a contraceptive DST.

METHODS

We conducted 21 semi-structured interviews with unmarried women aged 18-29 from an integrated health care system who viewed the DST. Thematic analysis was conducted to identify common themes in the participants' experience.

RESULTS

Four themes were identified: Informative; Narrowing down options; Tool vs. doctor; and Preparation for a clinical visit. In general, participants felt the tool was valuable because it provided them relevant information and facilitated their decision-making process by narrowing down contraceptive options. Participants felt the tool could prepare them for a visit with their health care provider by helping them identify questions for their provider, but also saw distinctions between the DST and what their provider could offer.

CONCLUSION

Contraceptive DSTs are valuable to their users when they include information on contraceptive attributes women deem important and allow for user-driven tailoring.

PRACTICE IMPLICATIONS

Contraceptive DSTs may address patient informational needs and can serve as a complement to provider counseling.

Women's Contraceptive Preference-Use Mismatch

BACKGROUND

Family planning research has not adequately addressed women's preferences for different contraceptive methods and whether women's contraceptive experiences match their preferences.

METHODS

Data were drawn from the Women's Healthcare Experiences and Preferences Study, an Internet survey of 1,078 women aged 18-55 randomly sampled from a national probability panel. Survey items assessed women's preferences for contraceptive methods, match between methods preferred and used, and perceived reasons for mismatch. We estimated predictors of contraceptive preference with multinomial logistic regression models.

RESULTS

Among women at risk for pregnancy who responded with their preferred method (n = 363), hormonal methods (non-LARC [long-acting reversible contraception]) were the most preferred method (34%), followed by no method (23%) and LARC (18%). Sociodemographic differences in contraception method preferences were noted (p-values <0.05), generally with minority, married, and older women having higher rates of preferring less effective methods, compared to their counterparts. Thirty-six percent of women reported preference-use mismatch, with the majority preferring more effective methods than those they were using. Rates of match between preferred and usual methods were highest for LARC (76%), hormonal (non-LARC) (65%), and no method (65%). The most common reasons for mismatch were cost/insurance (41%), lack of perceived/actual need (34%), and method-specific preference concerns (19%).

CONCLUSION

While preference for effective contraception was common among this sample of women, we found substantial mismatch between preferred and usual methods, notably among women of lower socioeconomic status and women using less effective methods. Findings may have implications for patient-centered contraceptive interventions.

Urban Adolescents' and Young Adults' Decision-Making Process around Selection of Intrauterine Contraception

STUDY OBJECTIVE

To examine adolescent and young adults' priorities, values, and preferences affecting the choice to use an intrauterine contraceptive device (IUD).

DESIGN

Qualitative exploratory study with analysis done using a modified grounded theory approach.

SETTING

Outpatient adolescent medicine clinic located within an academic children's hospital in the Bronx, New York.

PARTICIPANTS

Twenty-seven women aged 16 to 25 years of age on the day of their IUD insertion.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We conducted semistructured interviews exploring participant's decision making process around selecting an IUD. We were specifically interested in elucidating factors that could potentially improve IUD counseling.

RESULTS

We identified 4 broad factors affecting choice: (1) personal; (2) IUD device-specific; (3) health care provider; and (4) social network. Most of the participants perceived an ease with a user-independent method and were attracted by the high efficacy of IUDs, potential longevity of use, and the option to remove the device before its expiration. Participants described their health care provider as being the most influential individual during the IUD decision-making process via provision of reliable, accurate contraceptive information and demonstration of an actual device. Of all people in their social network, mothers played the biggest role.

CONCLUSION

Adolescents and young women who choose an IUD appear to value the IUDs' efficacy and convenience, their relationship with and elements of clinicians' contraceptive counseling, and their mother's support. Our results suggest that during IUD counseling, clinicians should discuss these device-specific benefits, elicit patient questions and concerns, and use visual aids including the device itself. Incorporating the factors we found most salient into routine IUD counseling might increase the number of adolescents and young women who choose an IUD as a good fit for them.