Patient-Centered Support for Contraceptive Decision-Making

Study Overview
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Brief Summary
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The investigators have designed a tablet-based decision support tool to help women learn more about their birth control options and support them in choosing a method they are happy with. The investigators will test whether the decision support tool helps women choose a birth control method they can continue using successfully by having some women use the tool before their birth control-related visit to a health care provider, and some women not use the tool before their visit. The investigators will then follow up with all the women at four months and seven months after their visit to see if they are still using the birth control method they chose at the visit and how happy they are with the method. Hypotheses: Women who use the contraceptive decision support tool will be more likely to continue using their chosen method at 4 and 7 months follow-up, compared to women who receive usual care. The contraceptive decision support tool will increase women's knowledge, choice of, and use of highly effective reversible contraception, compared to usual care. The contraceptive decision support tool will decrease decision conflict, compared to usual care. The contraceptive decision support tool will increase patient satisfaction with the clinic visit and with their method, compared to usual care. Women who use the contraceptive decision support tool will have fewer unintended pregnancies during the follow-up period, compared to women who received usual care. The contraceptive decision support tool will increase shared patient-provider decision making in contraceptive counseling visits, compared to usual care. The contraceptive decision support tool will decrease provider frustration when providing contraceptive counseling and increase provider job satisfaction. Women using the tool will be more likely to report use of any moderately or highly effective method of contraception at 4 and 7 months follow-up, compared to women not using the tool.

Detailed Description
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The impacts of unintended pregnancy include adverse maternal and infant outcomes for women who continue their pregnancies, with higher rates of infant low birth weight, infant mortality, and maternal mortality and morbidity for these pregnancies as compared to planned pregnancies. In addition, children resulting from unplanned pregnancies have been found to be more likely to experience developmental delay. Over the past several decades, the proportion of unintended pregnancy in the United States has remained stubbornly high at approximately 50%. Each year, one in 20 women of reproductive age experiences an unintended pregnancy, and it is estimated that over half of women will have an unintended pregnancy in their lifetime. This high rate of unintended pregnancy in the United States places a heavy burden on both women and the health care system. A disproportionate amount of this burden is experienced by minority women and women of lower socioeconomic status. Given the high rate of unintended pregnancies in this country, interventions designed to help women achieve their fertility goals could have a substantial impact on their health outcomes and life course. In addition, identifying strategies that are appropriate for use in high-risk, diverse populations could address disparities in women's ability to plan their pregnancies. The investigators propose a cluster randomized trial to investigate the effect of an interactive, tablet-based contraceptive decision support tool that women will use immediately prior to their contraceptive counseling visits. The goal of the tool is to facilitate shared decision-making between the woman and her health care provider, with the ultimate goal of helping the woman to choose a contraceptive method that is consistent with her values and preferences, and is therefore best suited to helping her to avoid an unplanned pregnancy. The tool will be available in both English and Spanish. The investigators will measure the tool's effect on women's contraceptive continuation, as well as on their experience of contraceptive counseling, measured both quantitatively and qualitatively. In addition, the investigators will collect quantitative and qualitative data to determine the impact of the implementation of this tool on the experiences of providers and the clinics in which they work.

Official Title
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Patient-Centered Support for Contraceptive Decision-Making: A Cluster Randomized Controlled Trial of a Contraceptive Decision Support Tool

Conditions
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Contraception, Contraceptive Behavior

Intervention / Treatment
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* Behavioral: Contraceptive Decision Support Tool


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients Women of reproductive age (15-45) Wish to discuss starting or changing a contraceptive method during their visit Speak, read, and understand English or Spanish (Note: for the pre- and post-intervention audio recording phases, only patients who can speak, read, and understand English easily will be enrolled.) History of sexual activity with men Providers Provide contraceptive counseling in one of the participating clinics Plan to remain in job role for at least six months Clinic staff Work at one of the participating clinics Had a job that included patient contact, but did not solely consist of family planning counseling at the time of the implementation of the intervention Exclusion Criteria: Patients Previously enrolled in the study Previously used the decision support tool at the Women's Community Clinic in San Francisco Are unable to get pregnant Appointment reason is for insertion of IUD or contraceptive implant Currently pregnant Desire pregnancy currently or in the next seven months (Note: The last criterion is designed to ensure we will have limited numbers of women that will discontinue their contraceptive methods during the study due to planning a pregnancy.)

Ages Eligible for Study
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Minimum Age: 15 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Contraceptive Decision Support Tool<br>Patients whose contraceptive counseling visits are scheduled with providers randomized to this arm will use the intervention immediately before their visit and bring the generated printout to their visit. Providers randomized to this arm will be free to integrate the tool and printout into their contraceptive counseling however they see fit. | Behavioral: Contraceptive Decision Support Tool<br>* The decision support tool: Provides an educational session about different aspects of contraception Elicits patient preferences about different aspects of contraception Identifies potential contraindications to certain contraceptive methods Allows the patient to view details about and compare available contraceptive methods Suggests methods most appropriate based on the patient's preferences Collects questions the patient may have for her provider Generates a printout the patient can bring to her contraceptive counseling visit<br>|
| No Intervention: Usual Care (Control)<br>Patients in this arm will receive usual family planning care. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Contraceptive Continuation | Whether or not a participant is still using the contraceptive method she selected at baseline. | 4 and 7 months post-enrollment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient Contraceptive Counseling Satisfaction | Patient-reported score on an 11-item factor analysis-validated measure created by the PI to assess patients' satisfaction with the contraceptive counseling experience. The measure consists of 5-point Likert scale items on which patients evaluate provider performance, with item response options ranging from 1 (Poor) to 5 (Excellent). The score range for the total measure is11-55, with 11 as the worst possible score and 55 as the best possible score for provider performance. Analyzed dichotomously, top score (55) versus all lower scores. | Baseline, post-visit survey | 
| Patient Satisfaction With Information Received About Side Effects During Counseling | Patient response to a 5-point Likert scale item about satisfaction with information that their provider gave them about side effects of their chosen methods during their baseline visit (1=completely unsatisfied, 5=completely satisfied). Analyzed dichotomously as top score of 5 versus <5. | Baseline (post-visit survey) | 
| Overall Satisfaction With Visit | Patient report on 5-point Likert scale of satisfaction with baseline visit (1=completely unsatisfied, 5=completely satisfied). Analyzed dichotomously as top score of 5 versus <5. | Baseline (post-visit survey) | 
| Shared Decision Making - Feelings About Provider Involvement | Patient report on 3-point scale of their feelings about provider involvement in contraceptive decision-making: I wish provider had been less involved, provider was involved the right amount, I wiss provider had been more involved. | Baseline (post-visit) and up to 24 months | 
| Shared Decision Making - Provider Appropriately Expressed Preference | Patient report of attitude on 3-point scale on how provider expressed preference for contraceptive method choice: Right amount, wish less strongly, wish more strongly. | Baseline (post-visit survey) | 
| Shared Decision Making - Satisfaction With How Provider Helped With Choice | Patient report of satisfaction on a 5-point Likert scale (from 1=completely unsatisfied to 5=completely satisfied) of how the provider helped contraceptive method choice. Analyzed dichotomously as top score of 5 versus <5. | Baseline (post-visit survey) | 
| Shared Decision Making - Who Made the Decision? | Patient response to 5-point scale of who made decision on contraceptive method. The original 5 points were the provider by themselves, more provider, both equally, more patient, or provider by themselves. In analysis, these options were collapsed to three points: more provider, both equally, or more patient. | Baseline (post-visit) | 
| Shared Decision Making - Provider Preference | Patient report of whether or not provider had preference for contraceptive method choice, reported on a 5-point scale: no preference, slight preference, moderate preference, strong preference, extremely strong preference. Analyzed dichotomously as any preference versus no preference. | Baseline (post-visit survey) | 
| Patient Decisional Conflict in Contraceptive Choice | Patient Decisional Conflict was measured using the Decisional Conflict Scale (DCS), a validated measure to assess patients' decisional conflict in medical decision making. The DCS includes 16 items about experience of conflict, with 5-point Likert response options ranging from 0 (Strongly disagree) to 4 (Strongly agree). Higher scores indicate less conflict. Top score on DCS (Range: 0-100, analyzed dichotomously as 100 versus <100). Top scores on subscales also analyzed (Informed decision, Uncertainty, Effective decision, Values clarity, Support, all ranging 0-100 and analyzed dichotomously as 100 versus <100). | Baseline (post-visit) | 
| Patient Knowledge of Contraceptive Options and Features | Patient responses to items derived from National Survey of Reproductive Contraceptive Knowledge and previous studies of contraceptive knowledge and attitudes. All items analyzed as correct vs. incorrect. | Baseline (post-visit) | 
| Patient Chosen Contraceptive Method Satisfaction | 5-point Likert scale item regarding patient satisfaction with contraceptive method chosen at baseline visit. The item is a statement of method satisfaction, and response options range from 1 (Completely disagree) to 5 (Completely agree). A higher score indicates higher satisfaction. Analyzed dichotomously as top score (5) versus all lower scores. | Reported and analyzed at baseline (post-visit), 4 months and 7 months follow-up | 
| Patient Current Contraceptive Method Satisfaction | 5-point Likert scale question regarding patient satisfaction with the contraceptive method they are currently using. The item is a statement of method satisfaction, and response options range from 1 (Completely disagree) to 5 (Completely agree). A higher score indicates higher satisfaction. Analyzed dichotomously as top score of 5 versus <5. | 7 months follow-up | 
| Patient Attitude Towards Use of Contraceptive Options | Patient ratings of contraceptive methods on the 11-point Global Contraceptive Attitude scale, developed by the PI. To assess overall (or global) attitude towards use of various methods, patients are asked to respond the following with regard to each method listed in the data table: Overall, how would you rate each of the following as a birth control method for yourself, (even if you've never used it)? Response options range from 0 (Terrible method) to 10 (Great method). A higher score on an individual item indicates a more positive attitude towards a method. Analyzed as discrete items with responses of 0 to 10; item scores not combined into an overall scale score. | Baseline (post-visit survey) | 
| Newly Heard About Methods During Visit | Percentage of patients who reported having heard about a method in the post-survey, but not the pre-survey. | Baseline (pre- and post-survey) | 
| Patient Rating of Visit as Much Better Than Previous Family Planning Visit | Patient report on 5-point Likert scale question asking patient to compare this visit to last family planning visit (1=Today was much worse; 5=today was much better). Analyzed dichotomously as top score of 5 versus <5. | Baseline (post-visit survey) | 
| Total Clinic Visit Time | Total amount of time a patient spends in a clinic for a family planning visit, from check-in to check-out. | Baseline visit | 
| Time Spent With Contraceptive Counseling Provider | Total amount of time spent with the provider that is providing contraceptive counseling. | Baseline visit | 
| Maslach Burnout Inventory | Provider participants were asked to respond to the Maslach Burnout Inventory on workplace burnout among human services workers. The scale includes 22 items with response options on a Likert scale of 0-6. Individual scores were calculated at both baseline and follow-up for three subscales: emotional exhaustion (Range: 0-54, with higher score representing higher emotional exhaustion), depersonalization (Range: 0-30, with a higher score representing higher depersonalization), and personal accomplishment (Range: 0-48, with a higher score representing more personal accomplishment in the workplace). | Change between baseline and end of study (up to 24 months post-enrollment). In multivariate analysis, follow-up score analyzed controlling for site and score at baseline (Analyses 1-3). | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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contraception, patient decision support, patient decision aid, shared decision making, Decision Making, Shared, Patient-Centered Outcomes Research