Objective
Due to time constraints that limit physician’s ability to deliver detailed contraception counseling, patients increasingly require supplemental education opportunities. Applications for smartphones and tablets are being designed to educate patients about contraceptive methods and simplify communication between patient and provider. We designed a mobile application entitled Plan A Birth Control to provide targeted information about the 10 most common, nonpermanent contraceptive methods with emphasis on long-acting reversible methods.
Study Design
We developed a mobile application designed to provide tailored information about the 10 most common nonpermanent contraceptive methods. After pilot testing with 40 volunteers from the clinic, 120 participants were recruited for a randomized controlled trial. ( ClinicalTrials.gov identifier: NCT02234271) Participants were assigned by simple randomization to contraception counseling via tablet or health educator. We compared participants’ contraceptive choice between the 2 groups. Secondary outcomes included knowledge of the method of choice and satisfaction with counseling.
Results
Of the 120 participants in the primary study, 65 chose long-acting reversible methods. The uptake of long-acting reversible contraceptives was similar between the groups (34 received health educator counseling and 31 received mobile application counseling). Both groups were demographically similar in age and educational status. Knowledge of long-acting methods did not differ significantly between the groups ( P = .30).
Conclusion
Results from our study suggest that Plan A Birth Control did not adversely affect highly effective birth control uptake in our study population. This can save time for physicians and health educators if used as an adjunct to contraception counseling in waiting room settings.
Approximately half of unintended pregnancies in the United States are due to contraceptive failure from inconsistent or improper use. Availability and quality of counseling have been shown to significantly impact individuals’ contraceptive selection and the effectiveness of their contraceptives use. Clinicians have limited time for detailed contraception counseling, creating a need for supplemental patient education opportunities. In response to this need, applications for smartphones and tablets can be designed to educate patients about contraceptive methods and simplify communication between patient and provider. These applications may increase the quality and efficiency of contraceptive counseling.
A number of mobile health applications related to contraception and family planning already exist. These applications offer to help women track menstrual cycles (identify the fertile days of the menstrual cycles) ; remind women about birth control pills, patch, or ring usage; and offer information about general sexual and reproductive health topics and/or locations of family planning centers.
The primary objective of our study was to design a comprehensive and medically accurate contraception counseling application and evaluate the effects of this contraception counseling application on the contraceptive methods that patients selected and their knowledge of that method.
Materials and Methods
Application development
A custom, English-language mobile health application entitled Plan A Birth Control was built with the help of a professional application development team ( Figure 1 ). The mobile application was designed to be accessed from electronic tablets (specifically iPads; Apple Inc., Cupertino, CA). The application displays information to users about the nonpermanent birth control methods most commonly recommended and requested at the University of California, Los Angeles (UCLA), Obstetrics and Gynecology Clinic, an outpatient clinic that is part of the UCLA Health System and located in Los Angeles ( Figure 2 ). Birth control methods described in the mobile application include the copper intrauterine device, hormonal intrauterine device, contraceptive implant, birth control shot, birth control pills, birth control ring, birth control patch, male condom, female condom, and diaphragm.
To create the content for the Plan A Birth Control application, we adapted material from 3 of the most commonly used patient information resources in our clinic: the California Family Planning, Access, Care, and Treatment (Family PACT) birth control education materials, the California Family Health Council fundamentals of family planning, and the bedsider World Wide Web site developed by the National Teen Pregnancy Prevention Campaign. From this we developed a script that was reviewed for accuracy by family planning division faculty at UCLA. The script was transformed into 2 separate documents: one for standard counseling by health educators and one for incorporating into the Plan A Birth Control mobile application. Both scripts had an estimated 6th-grade reading level (Flesch-Kincaid). The mobile application was built with introduction screens to emphasize the importance of overall health, preconception care, protection against sexually transmitted infections, and tips to choose birth control methods based on reproductive and life goals. The mobile application was also developed in such a way that very effective methods were presented first followed by the less effective methods. The application includes simple questions to screen patients for medical eligibility for birth control methods and has a built-in warning if the patient has any medical contraindication to the usage of method chosen. The built-in warning suggests that the patient should inform her health care provider about the medical condition in question prior to choosing a birth control method. Information about each birth control method was systematically placed under 7 headings: “what is it,” “how does it work,” “how to use it,” “how well it works,” “what are the benefits,” “side effects,” and “warning signs.”
We conducted a pilot test of this application with 40 volunteers who were patients at our obstetrics and gynecology clinic. Participants reviewed the application on iPads and then rated the appearance of the application, how easy it was to navigate, and the clarity and effectiveness of its content using scales of 1-10 (where 1 meant very poor and 10 meant excellent). Participants also had the opportunity to offer suggestions for improvement and were asked to include specific comments about 2 birth control methods they reviewed.
Study design and setting
We conducted a randomized controlled trial at the UCLA Obstetrics and Gynecology Clinic from October 2012 through May 2013. The UCLA Institutional Review Board approved the study. Participants were randomly assigned to receive contraception information from either a health educator or the Plan A Birth Control application. The study was conducted prior to the evaluation of participants by a physician. Eligible participants were 18-45 years of age, literate in English, not at that time using a contraceptive method or willing to switch to a new reversible contraceptive method, currently sexually active with a male partner, and intending to avoid pregnancy for at least 1 year. Women not at risk for unintended pregnancy–those who were pregnant, seeking pregnancy within the next 12 months, who had a history of surgical sterilization or a current partner who had had a vasectomy, using long-acting reversible birth control method, or who reported that they were going through or completed menopause–were excluded from the study.
Following screening and consent procedures, participants were randomly assigned to receive contraception information via Plan A Birth Control mobile application or via the health educator at the clinic. Participants in the tablet-based contraception counseling arm were given the electronic tablet by study coordinators and instructed on how to use the mobile application, while participants in the health educator counseling arm interacted with a traditional health educator to receive information about the different contraception methods. Health educators involved in the study were not physicians. They were a part of our clinic’s Title X health education program. They used a prepared script that contained the same contents as the mobile application as their guide for counseling patients. The health educators were instructed to talk with participants about the very effective methods first and then move on to the less effective methods. After the counseling session, the study coordinator identified the contraception choice of the participant (as reported in the survey) and a knowledge questionnaire was given to participants. All participants then completed their scheduled visit with physicians. At the end of their visit, participants received a gift card as a token of appreciation. After their visit, contraceptive choice was verified through the review of medical records.
The primary outcome was the effectiveness of contraceptive methods chosen by participants, which was divided into 3 groups: (1) very effective methods (copper and hormonal intrauterine devices or contraceptive implant); (2) effective methods (birth control shot, pills, patch, or ring); and (3) less effective methods (condoms or diaphragm).
Women who chose dual methods were categorized as choosing the method with higher effectiveness.
Secondary outcomes included knowledge of chosen method and patient satisfaction with counseling. If the participant chose any method other than those used by male partners (male condoms, withdrawal), a knowledge questionnaire was administered. As no questionnaire in the literature met the study’s objective, we designed a new questionnaire for that purpose. Faculty in the UCLA Family Planning Division reviewed the questions to establish face validity. During the pilot study of the tablet-based application, our patients evaluated readability of the questionnaire. The knowledge questionnaire included 6 items designed to measure each participant’s knowledge of the contraceptive method’s use, effectiveness, mechanism of action, benefits, side effects, and warning signs. We assessed participants’ knowledge of their method of choice only. (As women were to choose 1 from many options, including knowledge questions about all the methods before and after the intervention would have been difficult.) A single-item Likert scale was used to assess participants’ satisfaction with the contraception counseling they received.
Forty percent of the patients chose very effective birth control methods (intrauterine devices and implants) in the year 2010 through 2011. We calculated the sample size so that it would allow us to identify a change of 20%. We conducted a power analysis using G* Power 3.1.3 and determined that a sample size of 120 participants would yield a power of 0.80 (at alpha = 0.05). The sample size of 60 participants in each group gave us the ability to detect a change in corrected proportion by 0.20 between the tablet-based counseling group and the control group at the 5% level of significance and with power 80% (PASS 11 software; NCSS, Kaysville, UT).
We used a computer-generated list of random numbers (in blocks of 10) to allocate the participants. The allocation sequence was processed in sequentially numbered, opaque, sealed envelopes. These sealed envelopes were only opened after the enrolled participant completed all baseline assessment and it was time to allocate participants to the intervention. Data were collected through self-reported responses. Sociodemographic data and knowledge questionnaire were collected and participants’ reported choice of birth control method was documented. Following completion of the study, satisfaction about the contraceptive information given was noted as well. Data analysis was conducted among all those who provided consent. Baseline characteristics of participants in the 2 intervention groups were reported using frequency distributions and descriptive statistics including measures of central tendency and dispersion. The primary outcome of contraceptive choice (operationalized by proportion of women choosing long-acting reversible methods) was an unadjusted χ 2 test comparing the proportion of uptake in each intervention group. We then measured the average knowledge scores using independent t test between the 2 groups. Mann-Whitney test was used to compare the overall satisfaction scores between the groups. All analyses were performed using software (SPSS, IBM Corp, Armonk, NY).
Results
Pilot study results
There were 40 volunteers who participated in the pilot study. Mean age of the participants was 27 years (range, 18–44 years). Participants from all educational levels (32% ≤high school, 36% some college, 29% college graduate) took part in the pilot study. On average a participant spent about 15 minutes to view 2 assigned birth control methods. Satisfaction with information, overall look, images, colors, and other aspects of the mobile application were assessed using a visual analog scale ( Figure 3 ). Users were very satisfied with information provided in the application (mean satisfaction score 9.44 where 1 = not at all satisfied and 10 = very satisfied), clear information presented in the application (mean 9.34), and easily understandable information (mean 9.56). They particularly liked overall look of the application (mean 9.07 where 1 = very poor and 10 = very good), images in the application (mean 9.15), and colors in the application (mean 8.90). Ninety percent of the participants perceived the text size to be “just right.” Regarding navigation, mean score for overall navigation was 8.63 (where 1 = very poor and 10 = very good) and that of switching screens was 8.68. Some of the positive and constructive reviews by pilot study participants are described in Table 1 . Some of the constructive feedback was used to modify the mobile application before starting the randomized controlled trial.
| Positive reviews |
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| Constructive reviews |
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