User panel groups

The aims of these groups were to identify contraceptive attributes important to the decision-making process, building on an initial literature review, and to obtain input on language and definitions to be used in the aid. Three face-to-face groups were conducted and 20 people in total participated (15 women and 5 men), recruited through Brook and FPA networks. Thirty contraceptive attributes, in addition to avoidance of pregnancy and STIs, were identified. These fell into three broad categories: negative side effects, benefits and ‘bother’ factors (Table 1). Short-term acceptability-related factors that affect decision-making were priveleged over longer-term costs and benefits, such as increased risk of thrombosis and decreased risk of endometrial and ovarian cancers amongst combined oral contraceptive (COC) pill users for two reasons. First, the risk of these events attributable to contraceptive use is small and so would be unlikely to affect MCT's recommendation even if the user places a large proportion of weight on one of these outcomes. Second, and more pragmatically, if all possible adverse events are included the list of attributes would be extensive. Information about long-term effects associated with contraceptive use is avaiable on the Brook and FPA websites. In addition, a section on ‘Frequently Asked Questions’ to explain how the tool works and to address any user queries was added.

Once the tool was developed, wider feedback from members of the user panel groups was obtained online, with users testing the aid and sending through their comments (see Online piloting and testing).

Questionnaire

Personal criteria are obtained through the completion of the online questionnaire, which is part of MCT and uses the Elicia sofware. The questionnaire's purpose is to ensure:

1. Customisation for each user through survey modifiers, for example, different questions are asked depending on gender;

2. Personalisation through topic modifiers so that (i) individuals are linked in the underlying decision analysis framework to evidence that most fits their current circumstances, for example, ensuring that data are age-specific where relevant; and (ii) contraceptive options can be filtered out depending on the user's responses, for example, responses to medical history questions may suggest that specific contraceptive methods are contraindicated; and

3. Relevant information is collected for research purposes.

Data from the questionnaire can be used, with the user's consent, for monitoring and evaluation purposes. The question topics were developed from literature review and from discussions during the user panel groups. Where appropriate, validated questions were used, for example from the National Survey of Sexual Attitudes and Lifestyles (Natsal 2000). Topics included: socio-demographic characteristics (e.g. age, gender and geographical region), sexual behaviour (e.g. partnership status, number of sexual partners in the last year), contraceptive and reproductive history (e.g. contraceptive method ever and currently used, parity), medical history to identify contraindications to specific contraceptive methods (e.g. whether or not a smoker, use of medication), identification of acceptability-related attributes of contraceptive methods that most affect decision-making (Table 1), and whether users are surprised by the contraceptive method suggested and whether they are likely to use it. Users can indicate whether they want to complete the short questionnaire, which takes around 5 minutes to complete, or the longer questionnaire, which takes around 15 minutes to complete. The longer version includes questions on contraceptive and reproductive history and medical history, and is recommended for women aged 35 years and above.

Collection of evidence

In the main, best available evidence for the underlying decision analysis for each of the 15 contraceptive options included in MCT was obtained from Faculty of Sexual & Reproductive Healthcare guidelines and relevant Cochrane reviews (full details on the evidence base used in MCT is available on request from the authors). Where possible, data relevant to the UK population was used. The probability of an outcome happening at 1 year follow-up, again where possible, was collected, such as the chance of pregnancy within 1 year. Behavioural data that might affect STI risk, such as number of sexual partners and prevalence of STI acquistion by age and gender (chlamydial infection was used as a proxy measure), was obtained from Natsal 2000.11 Definitions were provided where appropriate (e.g. no periods or amenorrhoea was defined as no bleeding for more than 90 days). Where there was no evidence available, clinical guidance was sought to provide the estimates. The evidence used in the underlying decision analysis framework was reviewed by a clinical advisor at FPA. UK Medical Eligibilty Criteria (UKMEC) guidelines were used to identify contraceptive methods that may be contraindicated due to a user's medical history.12 Methods are removed from the list of contraceptive options if a Category 3 (‘theorectical or proven risks outweigh the advantages’) or a Category 4 (‘unacceptable health risk’) condition is reported by the user. For example, COCs are removed if a female user is a smoker and aged 35 years or older. Data for each contraceptive method and attribute were entered into Excel spreadsheets, which were then uploaded into Annalisa. MCT is very much a ‘living’ aid and can be easily updated as new evidence or guidelines become available.

In relation to ‘bother’ or inconvenience attributes, users are the experts and are asked to provide their own ratings on how important these attributes are to the decision. For example, if a user indicates that having to remember when to take or use a contraceptive method is an important consideration, they are then asked how difficult would it be for them to remember to take or use a contraceptive method, from ‘extremely difficulty’ (rated as 0.9) to ‘slightly difficult’ (0.2). These responses are then used in the underlying decision analysis.

Online piloting and testing

User panel members, health care providers and academics working in sexual health, and volunteers from Brook were invited to participate in the online pilot. This process allowed us to test the clarity of instructions and definitions, question validity, and the usability and functioning of the tool (e.g. skips within the questionnaire and question layout). Staff working within Brook and the FPA tested the tool using different case scenarios, for example, how the tool worked when used by young people under the age of 16 years. In March 2010, FPA sent the pilot questionnaire out to their external group of 12 contraception experts for testing. In total, 78 individuals submitted their responses to the pilot questionnaire, together with comments on MCT, which we were able to examine and address, where required, prior to the launch.

Rachael

Rachael is a 38-year-old smoker and neither she nor her husband want any more children. She completes the longer questionnaire. She reports heavy menstrual bleeding and she would like a method to help reduce this. The attributes Rachael is most concerned about when choosing a contraceptive method are weight gain of more than 2 kg, irritability or depression, and having to remember when to take or use contraception. She indicates that she finds it fairly difficult remembering when to take or use contraception.

Rachael is then asked to indicate how much she is concerned about pregnancy, STIs and her selected attributes by moving the blue bars in the ‘weightings’ section. In Figure 1, it shows that Rachael is most concerned about pregnancy (the longest blue bar), followed by weight gain, having to remember when to take or use contraception, irritability or depression, and finally STIs (the shortest bar). In terms of benefits she places a relatively large weight on having less menstrual bleeding. The top section scores all the appropriate contraceptive methods according to their suitability for each user depending on their responses to the questionnaire. As Rachael is aged over 35 years and is a smoker, the COC pill has been removed from her list of options. The suggested method for Rachael, based on her age, medical background, concerns and desired benefits, is the intrauterine system. This is highlighted by the darkest bar.

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Figure 1

The results screen with Rachael's selected attributes and weightings. NB. The weights entered and shown in these figures do not add up to 1 (i.e. they are non-normalised). In Annalisa^©, weights are normalised so they total 1 and can be used in the underlying calculations to produce the scores for each of the contraceptive options.

Joe

Joe is 18 years old and he has had five sexual partners over the last year. He completes the short questionnaire. The concerns he identifies include having to go to a clinic (which he would find very difficult), relying on his partner to remember to use or take contraception (fairly difficult) and any loss of sensation during sex (fairly difficult). The method suggested to Joe based on his responses and the weight he gives to his selected attributes is the male condom. Male and female sterilisation have been removed from his options because of his age (Figure 2).

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Figure 2

The results screen with Joe's selected attributes and weightings.

Users are encouraged to adjust the length of the blue bars to see how changing the weights that they place on their selected attributes affects the results.