Mobile health (mHealth) technology and interventions have been proven to affect behavior change in the areas of obesity and smoking, but their effect on contraception behavior remains unproven, according to recent research.1
Using mHealth in reproductive healthcare has helped increase patients’ knowledge of contraception methods, but there was no conclusive research on whether the interventions could change behavior, says Alice F. Cartwright, MPH, lead study author and a PhD candidate in the department of maternal and child health at the University of North Carolina at Chapel Hill.
“We did a search that narrowly looked at interventions delivered via a mobile phone or a tablet,” Cartwright says. “Those are SMS text messages on a mobile phone or tablet.”
Investigators did not study interventions that included phone calls or that were computer interventions. “We were interested in things that were on devices that people had regular access to,” Cartwright explains. “We ended up finding 18 studies that fit our criteria. We looked at those studies, what they were using, where they focused on initiation or continuation, and what were the characteristics of the participants.”
No Effect on Initiation, Continuation
Cartwright and colleagues found some surprises. For one, the use of text messages was not as ubiquitous as they anticipated. “We think technology is moving so fast, and we use apps for everything,” she says. “It’s a slow process for developing an intervention, getting the results, and publishing it.”
More than half the interventions included text messaging. Four interventions used mobile apps on tablets that were given to patients ahead of clinic visits. The remaining studies combined both.
“One was a mobile app on a participant’s smartphone. Another was an app. They also sent SMS, and a couple were a hybrid of that,” Cartwright notes. “Eleven out of 18 used SMS texting, which is the cheapest and simplest method.”
The biggest surprise was that almost none of the interventions showed any effect on contraceptive initiation or continuation. “There were a couple of studies that did find an impact from their intervention,” she says. “However, some of those intervention designs were not very strong, or the outcomes that were recorded were often self-reported.”
For example, the results of one study revealed that text messages tailored to Native American/Native Alaskan youth and their cultural identity resulted in a significantly higher condom use at follow-up.1
“But that was self-reported,” Cartwright says. “There [possibly] was a response bias that people want to say they’re using condoms because that’s what people want them to say.”
Even the interventions that used mobile apps on tablets before clinical visits did not show any significant difference in contraceptive initiation. “Many of those studies were trying to see if they could influence increased uptake of long-acting, reversible contraception,” she explains. “They didn’t see any difference between groups with standard counseling on a full array of methods vs. using these apps.” Additional features, including video testimonials, were embedded in the apps.
More Research Is Needed
The findings suggest that researchers still need to identify and study what influences people’s contraceptive behaviors and decisions in initiating and continuing a method.
“Could we measure satisfaction with the information or counseling or the reminders that people got from the intervention?” Cartwright asks. “Is that the factor that maybe contributed to them initiating or continuing a method?”
Side effects might influence patients’ continuation over time, and these might not have been addressed with existing interventions. “Most of the continuation interventions were just reminders to people to take an oral contraceptive pill or to return to the clinic for a method-related appointment,” she explains. “We definitely need to think about patient satisfaction with the counseling or the method and how we can facilitate that through these mHealth tools.”
The various methods of using mHealth tools included one group that sent participants educational or motivational text messages about using a contraceptive method. The control group received only positive health messages that were not specific to family planning.
“Some got information on a tablet, and others got whatever was standard of care for the clinic — often, in-person counseling. I think there is such great opportunity to use mHealth even to support people to meet their reproductive goals, but it’s almost like we did the first wave with excitement because people have phones and we wondered how we could reach people using their phones to impact behavior,” Cartwright explains. “Now, we have seen what that looks like, and we need to think a little more creatively and critically about what kinds of intervening mechanisms or levers could actually help change behavior.”
Cartwright and colleagues also noted while some of the messages were text messages, they did not link people to services. “Obviously, people who come into a clinic and get a tablet have overcome that barrier,” she says. But by not including links to services, they could have missed an opportunity to give people a chance to act on their motivation to initiate contraception.
Another consideration is including opportunities for patients to give feedback electronically. “Are they having concerns about their method or the side effects?” Cartwright asks. “We have so many opportunities to communicate electronically, whether through text messages, telehealth, or whatever, so what are their opportunities to speak with someone and discuss any concerns about the method they have?”
Those discussions — even if held through text message or email — could help patients continue on their chosen method. “A lot of the interventions that looked at continuation were just reminders of to not forget to take their pill today or to not forget to return to the clinic for the next injection,” she explains.
There was no information about why a patient might have stopped a particular method. “Maybe we have to remember, in our excitement to use new interventions, to not forget that people like to talk to a real person and ask questions,” Cartwright says.
REFERENCE
- Cartwright AF, Alspaugh A, Britton LE, Noar SM. mHealth interventions for contraceptive behavior change in the United States: A systematic review. J Health Commun 2022;27:69-83.