June 26, 2014 — Summary of "Development and Testing of an iOS Waiting Room 'App' for Contraceptive Counseling in a Title X Family Planning Clinic," Gilliam et al., American Journal of Obstetrics and Gynecology, May 29, 2014.
Long-acting reversible contraceptives (LARC) "require few use behaviors" and are "highly effective," but a "[l]ack of awareness of and misinformation about" the methods may contribute to their low rates of use, according to Melissa Gilliam of the family planning and contraceptive research section of the University of Chicago's Department of Obstetrics and Gynecology and colleagues.
One "novel platform" for offering information about LARC is "[i]nteractive, multimedia, computer-based programs," such as iOS applications, or apps. The researchers sought to test the impact of an app on awareness of and interest in LARC by offering it to women in a clinic waiting room.
The researchers began by assessing barriers to intrauterine device (IUD) use among women ages 15 through 29 at three Chicago Title X family planning clinics from January 2011 to May 2011. They reviewed administrative data and met with clinicians, staff members and patients to identify factors that negatively affected contraceptive counseling.
They found that contraceptive counseling was often hindered by time constraints, nonuse of pamphlets in waiting rooms and clinicians' failure to counsel all patients on LARC. In particular, not capitalizing on waiting room "down time" was identified as a missed opportunity to engage patients. Thus, the researchers "opted to create a counseling app to promote interest in and awareness of LARC."
In developing the app, the researchers aimed to incorporate planned behavior theory; improve LARC awareness while also offering information on other contraceptive options; appeal to a variety of learning styles; feature "unbiased, evidence-based content"; and work within the existing clinic flow. The app also included video testimonials featuring two women from the clinics who were using the IUD or implant.
The researchers tested prototypes of the app through a randomized controlled trial from August 2012 to March 2013 at a Title X clinic. Participants completed demographic and baseline knowledge questionnaires and were randomly assigned either to receive standard care or be given a tablet computer to use the app for up to 15 minutes in the waiting room, followed by a survey on their experience and then standard care. The researchers also assessed participants' medical charts one month after their visits to determine which contraceptive method they chose and how the method was provided.
The researchers found that the "primary app design challenge" was determining how to present LARC-focused content that was also "comprehensive for all contraceptive methods." Testers during the design process preferred certain content presented in specific ways, such as absolute numbers rather than percentages of effectiveness, they found.
The final sample included 52 participants, including 28 in the intervention group and 24 in the standard care group. Participants had a median age of 22.5 years, and the majority self-identified as Black/African-American.
The researchers found that "[u]se of the app translated to improvements in knowledge of contraceptive effectiveness," with participants in the intervention group scoring "significantly higher" on two of three knowledge questions and higher overall on the knowledge assessment.
At baseline, interest in the IUD was higher than interest in the implant for both groups. There was no difference in IUD interest among app users post-intervention, but their interest in the implant increased significantly.
Most participants in both groups who selected LARC chose an IUD. There were no significant differences between the intervention group and standard care group in terms of LARC selection.
More than 90% of app users agreed or strongly agreed that the app was easy to use, taught them new information about birth control, offered information they would use in the future and represented a good use of their time. Further, 74% of users agreed or strongly agreed that the video testimonials were "interesting."
"This study presents an innovative process for developing and testing a contraceptive counseling tool," the researchers wrote, adding that the app "complemented the clinical visit, took advantage of the clinic wait time, shifted some of the counseling burden, and did not interfere with clinic flow."
Further, the "brief (<15 min) app sessions significantly improved women's knowledge scores on the relative effectiveness of LARC compared with other methods."
Overall, the "study demonstrate[d] that an app can be highly acceptable, informative, and easily integrated into the Title X setting, for use by low-income women," the researchers wrote, adding that "it is conceivable that the app could be downloaded by women onto their smartphones in advance" of a clinic visit.
Therefore, the researchers concluded, "apps could be a mechanism for implementing timely, evidence-based educational information to a wide network of clinics and clients."