Title: Improving Contraceptive Method Choice and Use with a Computer-Based Contraceptive Assessment Module
Description: Unintended pregnancy is prevalent and persistent in the United States, with significant public health costs. Paralleling disparities in other reproductive health outcomes, some population subgroups are more likely to have an unintended pregnancy than others. Use of highly effective contraceptive methods can reduce unintended pregnancy rates. Interventions to help those at highest risk of unintended pregnancy are of critical public health importance, yet few interventions have been found to significantly impact contraceptive method choice and use, and even fewer have been designed for populations with low educational attainment. The current dissertation research was designed to meet the need for interventions appropriate for women with low educational attainment, addressing a significant gap in the literature on interventions to improve contraceptive choice and use. A three-arm randomized controlled trial of a bilingual (Spanish/English) contraceptive assessment module using audio-computer-assisted self-interviewing technology and touchscreen computers was conducted from March 2008 - January 2011 among family planning patients seeking care at two federally-funded family planning clinics in New York City.

The three-arm design was used to test separately the effect of the assessment module and the effect of tailored health materials: participants were randomized to complete the module and received health information materials tailored to their responses to the module questions (Intervention + Tailored); to complete the module and receive generic material (Intervention + Generic); or to a control condition (Control). Contraceptive method choice on the day of the family planning visit was the primary outcome. Follow-up analyses among a randomly-selected subset of patients examined secondary outcomes, including continuation and adherence to the chosen contraceptive method 4 months after the family planning visit. In intent-to-treat analyses adjusted for clinical recruitment site (n=2,231), family planning patients who used the module were significantly more likely to choose an effective contraceptive method (a method with fewer than 10 pregnancies among 100 women in one year typical use): 75% among those who received tailored materials [Intervention + Tailored OR=1.56 (95% CI: 1.23-1.98)] and 78% among those who received generic materials [Intervention + Generic OR=1.74 (95% CI: 1.35-2.25)], compared to 65% among control arm participants.

Tailored health information materials, compared to generic materials, did not have significant impact on contraceptive method choice. These findings were consistent in as-treated analyses among participants who completed the module and data collection procedures on the day of their family planning visit, in analyses comparing different sources of outcome data, and in sensitivity analyses accounting for missing outcome data. In a subset of participants randomly selected for participation in a follow-up survey 4 months after their family planning visit (n=224), those in the Intervention + Tailored arm were significantly more likely to continue use of the contraceptive method chosen on the day of their family planning visit, with 95% continuing use, compared to 77% in the Control arm (OR adjusted for clinical site of recruitment = 5.48 [95%CI: 1.72-17.42]). No significant difference in continuation was found between the Intervention + Generic and Control arms. The dissertation research has numerous strengths.

The easily replicable, single-session intervention was designed for use by populations with low educational attainment or low literacy skills. The randomized controlled trial included more than 2,000 family planning patients, half of whom were Spanish-speaking. Effectiveness research evaluating the impact of the intervention under "real-world" conditions of implementation, in a broadly defined population, is merited. Such evaluation should include measures not fully explored in this phase, including the impact of the module on provider visit time, and analyses of continuation and adherence outcomes over a longer period of time.