Elsevier

Contraception

Volume 86, Issue 4, October 2012, Pages 383-390
Contraception

Original research article
Randomized controlled trial of a computer-based module to improve contraceptive method choice

https://doi.org/10.1016/j.contraception.2012.01.013Get rights and content

Abstract

Background

Unintended pregnancy is common in the United States, and interventions are needed to improve contraceptive use among women at higher risk of unintended pregnancy, including Latinas and women with low educational attainment.

Study Design

A three-arm randomized controlled trial was conducted at two family planning sites serving low-income, predominantly Latina populations. The trial tested the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients choosing an effective method of contraception (<10 pregnancies/100 women per year, typical use). Participants were randomized to complete the module and receive tailored health materials, to complete the module and receive generic health materials, or to a control condition.

Results

In intent-to-treat analyses adjusted for recruitment site (n=2231), family planning patients who used the module were significantly more likely to choose an effective contraceptive method: 75% among those who received tailored materials [odds ratio (OR)=1.56; 95% confidence interval (CI): 1.23–1.98] and 78% among those who received generic materials (OR=1.74; 95% CI: 1.35–2.25), compared to 65% among control arm participants.

Conclusions

The findings support prior research suggesting that patient-centered interventions can positively influence contraceptive method choice.

Introduction

Unintended pregnancy is common in the United States: one half of women of reproductive age (15–44 years) have had at least one unintended (either mistimed or unwanted) pregnancy [1], [2]. A full 10% of women of reproductive age in the United States become pregnant each year [3]. Of 6.7 million pregnancies in 2006, nearly half (3.2 million) were unintended; 36% of these unintended pregnancies resulted in live birth, 21% resulted in spontaneous abortion, and 43% resulted in induced abortion [4]. Paralleling other health outcomes, there are significant sociodemographic disparities in unintended pregnancy, with higher rates reported among low-income women [4], [5], [6] compared to those with higher incomes, and among black women and Latinas compared to white women [7]. Socioeconomic disparities in rates of unintended pregnancy have, in fact, widened since the mid-1990s [1], [4], [6]. Contraceptive choice and use are important factors in unintended pregnancy: one analysis estimated that the overall rate of unintended pregnancy could be reduced by half if women were to choose and use highly effective contraception [8]. Interventions are needed to improve contraceptive choice and subsequent use among women at higher risk of unintended pregnancy.

A recently completed Institute of Medicine report on federally funded family planning services cited the lack of evidence of proven efficacy of contraceptive counseling methods or interventions [9]. Despite documented socioeconomic disparities in unintended pregnancy [4], [6] and the established link between socioeconomic status and literacy skill level [10], few interventions [11], [12], [13], [14] have been specifically designed to reach populations with low educational attainment or with low functional health literacy skills [10], [15], [16], [17], [18]. Many studies of interventions to improve contraceptive choice or use have lacked internal validity [19], while others have been statistically underpowered [14], [20]. Those interventions that have been found to have a significant impact on contraceptive method choice are intensive, occurring over multiple sessions and limiting opportunities to translate them at the population level [21], [22].

To address the lack of single-session structured interventions suitable for use in populations with low educational attainment, a contraceptive choice algorithm [23] was adapted into a module incorporating audio-computer-assisted self-interviewing (ACASI) and touchscreen technology. Interventions using ACASI targeting other health outcomes have been found to be an effective modality for low literacy populations [24], [25]. A three-arm randomized controlled trial of the module was conducted in two urban family planning clinics serving low-income predominantly foreign-born Latinas to test its efficacy in increasing the proportion of patients choosing an effective contraceptive method.

Section snippets

Study design and setting

A three-arm randomized controlled trial to test the efficacy of a computer-based contraceptive assessment module for increasing the proportion of patients choosing an effective method of contraception was conducted over 2 years at two publicly funded family planning centers in a shared clinical network in New York City. All study materials were available in both English and Spanish. Participants were randomized to use the computer-based contraceptive assessment module and receive tailored

Enrollment

As shown in Fig. 1, a total of 6502 women were screened for participation in the study over the 18-month course of recruitment. Of these, 1847 (28%) were ineligible because they had already participated at a prior visit, 658 were ineligible for other reasons (10%), 1431 (22%) declined participation, 70 (1%) began the consent process but did not initiate the module, and 48 did not have a provider visit on the day of recruitment (<1%), yielding 2448 women who consented to participate (and were

Discussion

In a randomized controlled trial, women who used a self-guided computer-based contraceptive assessment module were significantly more likely than women assigned to a Control group to choose an effective method of contraception (with 10 or fewer pregnancies among 100 women in 1 year of typical use) at the time of their visit. Our findings support prior research that suggested that patient-centered counseling can influence contraceptive method choice [31], [32], [33], [34], [35], [36]. Because

Acknowledgments

This project was made possible through grants from the National Campaign to Prevent Teen and Unplanned Pregnancy, the Bridge the Gap Foundation and a private foundation. The original algorithm, in English, developed at Emory University, can be accessed at www.bestmethodforme.com. The authors also wish to thank the study participants; Diana Castillo, Sarina Jean-Louis and the staff at MIC-Women's Health Services; Peggy Goedken, MPH; reviewers Roberta Scheinmann, M.P.H.; Mary Beth Terry, Ph.D.;

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    Dr. Kottke may be entitled to royalties derived from Best Method for Me related to the research described in this paper. This study could affect her personal financial status. The terms of this arrangement have been reviewed and approved by Emory University in accordance with its conflict of interest policies.

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