Reviewer's report
Title:Womens' preferences and values in contraceptive choice: a systematic
review of relevant attributes
Version:2Date:6 December 2013
Reviewer: Ward Rinehart
Reviewer's report:
Review comments on Wyatt et al., “Womens’ preferences and values in
contraceptive choice: a systematic review of relevant attributes,” submitted to
BMC Women’s Health.
Minor compulsory revision:
1. First off, please include the words “decision aids” in your title.
Discretionary revisions:
2. This article implies (and it should state explicitly) a simple but important
question: Do decision aids for contraceptive method choice address what matters
most to people choosing a method? I like the simple but revealing approach of
comparing survey findings with the decision aids themselves.
I am disappointed, however, that you did not go further in discussing their
findings. Really, you give the comparison just one paragraph of discussion (that
beginning on line 186). There are several questions that you could choose to
address:
2.a. To me, there is a more-or-less mirrored look to Figure 2, reflecting some
correspondence between survey responses and decision aids. Do you agree? If
so, that might be the starting place for the discussion.
2.b. You argue, rightly enough, that decision aids should reflect the concerns of
family planning clients; they imply that communicators should look to survey
findings to orient their decision aids. Given the findings shown in Figure 2,
specifically what factors of importance to clients have decision aids been
missing, in your opinion?
2.c. In the sentence starting at line 164, you note that several method attributes
mentioned in decision aids do not show up in survey findings. Would you suggest
that some of these might be dropped so as to simplify the decision aids and
avoid topics that clients find irrelevant?
2.d. At the same time, communicators might say that there are certain issues that
people should consider but often overlook (e.g., protection from STIs), and
decision aids have a duty to raise these potentially important issues. Should
decision aids address only the issues that most clients raise a priori (as the
thesis of this article implies), or should decision aids also raise new issues that a
client might find important?
2.e. You touch several times on the fact that different women consider different
attributes important to them. This is indeed the big challenge in designing a
decision aid--at least, designing one on paper; computer-based decision aids can
easily enable users to choose the topics they want to pursue. But even some
paper-based decision aids have taken the “meta” approach of asking the client
what is important to her/him about a method and then exploring those concerns.
In a sense these decision aids incorporate the survey question. What
recommendations do you have for the design of decision aids so as to
accommodate the differences among clients’ concerns?
2.f. You invoke the shared decision-making model, but there has been some
discussion in family planning circles whether this model really suits the decision
about contraceptive choice. In other words, how compatible—or how
conflicting—are the concepts of “shared decision-making” and “informed choice”?
In empirical terms, there is limited evidence (e.g., Pariani et al., 1991 ), that
family planning users continue a method longer when they get the method that
they wanted in the first place. If “getting what you want,” regardless of how “valid”
the reason for the choice in a health care provider’s eyes, is important to
successful use, to what extent should providers be guiding or influencing the
client’s choice?
2.g. I certainly agree with your call for more evaluation of decision-aids. It is
relatively easy to gauge impact on clients’ knowledge and to elicit their evaluation
of using a decision aid. But reaching down the hypothetical causal chain to see
what difference the decision aid made to behavior—either in choice of the
method or in its use (e.g., effectiveness, continuation)—has proved quite difficult.
Do you have any recommendations, based on their research, as to what would
be useful and measurable indicators?
3. Re strengths and weaknesses: One weakness of the approach is that we
cannot tell how often specific attributes were mentioned in survey
responses—only whether they were mentioned at all in a particular survey,
presumably. For the purposes of designing a decision aid, knowing which
attributes people mention most would be helpful. You touch on this issue in
passing but could be more explicit about the value of knowing the frequency
distribution of mentions of specific attribiutes . That analysis is a topic for a
separate meta-analysis.
4. Also, you might note that a great deal more goes into the success of a
decision aid than the topics it covers. Other important considerations (but off
course you need not mention all these) include whether the decision aids
enables the client to control or influence the decision-making process (as well as
the decision itself); whether the tool supports the provider’s counseling role and
use of the tool itself; whether the tool offers any support to the client for balancing
multiple concerns in reaching a decision; whether the flow of presentation is
intuitive; and whether the language, tone, and art work are appropriate to the
intended clients and communicate well.
Miscellaneous points:
5. While the introductory paragraph focuses on the US experience, some of the
decision aids identified were designed and are intended for worldwide use and
particularly for use in developing countries. Several (e.g., the WHO DMT and the
Population Council’s Balanced Counseling Strategy) were, in fact, evaluated in
developing countries. It would be helpful to note this (although not in this
paragraph, of course).
Also concerning the first paragraph: You present the statistics, but you fail to
draw any conclusion from them. How do these sorts of statistics motivate your
research? There’s no link with what follows.
6. I find the paragraph beginning on line 115 confusing. Why would you limited
the decision aids analyzed to those that had been the subject of a study, since
you apparently did look at the decision aids themselves to see what attributes of
methods they covered? In fact, the following paragraph suggests that you did
look for and find some job aids that were not covered by studies. Perhaps this is
simply a matter of a misleading description in the paragraph starting at line 115.
Also, were these surveys and semi-structured interviews really a tool for sharing
information, as you write, or were they asking women what attributes and
aspects of contraceptive methods are important to them? Given your overall
comparative approach, I assume the latter, but that’s not what you say here.
7. You raise the question whether survey responses truly describe what people
find important to the choice of a method or instead reflect the questions that the
various researchers chose to ask. I note that only four of the factors identified in
surveys show up in at least half of the surveys. Most show up in only a handful.
What do you make of that?
8. I find it difficult to make out from Table 1 which of the items listed show up on
the left side of Figure 2 and which on the right side. Could you make this
explicit—perhaps by dividing Table 1 into two panels? And what does it mean
that both the “Questionnaire/interview included” and “DA included” columns are
checked? Do they then show up on both sides of Figure 2?
9. Please explain briefly in the text what you mean by “vicarious experience,”
10. The manuscript could use some editorial tweaking throughout. For example,
“We conducted a systematic review to identify attributes about contraceptive
choice that may be important to women” (lines 45-46) would be better phrased,
“We conducted a systematic review to identify attributes of contraceptive
methods that may be important to women.” And “contraception use” when you
mean “contraceptive use” (line 75). Line 86 is missing the words “in
fact”—“reflected in the fact that.” And so on. I suggest that you ask a colleague or
an editor with a sharp eye for usage to review the manuscript.
11. You might want to take a look at the “daughters of DMT”: First, the WHO’s
“Reproductive choices and family planning for people living with HIV,” at
http://www.who.int/reproductivehealth/publications/family_planning/9241595132/en/index.html.
The approach is like the DMT’s. This tool addresses contraceptive choice but
also other important reproductive and health choices for people living with HIV.
Second, the community-level version of the DMT, “A guide to family planning for
community health workers and their clients,” at
http://www.who.int/reproductivehealth/publications/family_planning/9789241503754/en/index.html.
So far as I know, neither of these has been formally evaluated.
With the exception of the necessary improvement in the title, all the issues I
suggest discussing and other points here would be discretionary changes. I
strongly urge you, however, to explore your data further, raise and discuss
issues, and be more specific with their recommendations. Given the work
invested in collecting and analyzing the information, it would be a shame not to
explore it more deeply. All of us involved in the development of decision aids
would benefit—and, we would hope, so would the providers and clients who use
decision aids.
Ward Rinehart
Jura Editorial Services
Gex, France
6 December 2013
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests.