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Postby Shaktigis В» 20.04.2019

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Unintended pregnancy increases health risks for mother and child, leads to high economic costs for society, and increases social disparities. Mobile phone ownership is rapidly increasing, providing opportunities to reach at-risk populations with reproductive health information and tailored unintended pregnancy prevention interventions through mobile phone apps.

However, apps that offer support for unintended pregnancy prevention remain unevaluated. To identify, describe, and evaluate mobile phone apps that purport to help users prevent unintended pregnancy. Eligible apps were downloaded and categorized by primary purpose. Data extraction was performed on a minimum of attributes in 3 domains: 1 pregnancy prevention best practices, 2 contraceptive methods and clinical services, and 3 user interface.

Apps were assigned points for their inclusion of features overall and for pregnancy prevention best practices and contraceptive information. Our search identified app descriptions in iTunes and Google Play.

Of these, unique apps met inclusion criteria and were included in the review. Twelve apps scored at least 50 points out of 94 for overall number of features and at least 15 points out of 21 for contraceptive information and pregnancy prevention best practices. YA SRH apps had the highest percentage of pregnancy prevention best practices in each app. This review identified several useful, evidence-based apps that support the prevention of unintended pregnancy.

However, most apps miss opportunities to provide users with valuable information, interactive decision aids, and evidence-based interventions for unintended pregnancy prevention.

Further, some apps in this space may increase the likelihood of unintended pregnancy due to the low effectiveness of the contraceptive methods promoted. An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at the time of conception, as the result of interrelated factors associated with knowledge, access, and behavior [ 2 ].

Unintended pregnancy disproportionately affects younger women years old, African American women, and lower-income women, contributing to cycles of poverty and inequality in the United States [ 2 , 4 , 5 ]. For these reasons, reducing unintended pregnancy is a compelling and complex public health challenge and a national public health goal. One way that they are doing this is by supporting evidence-based family planning programs, including those that leverage smartphones to deliver reproductive health information [ 7 - 12 ].

However, most smartphone family planning research focuses on text-message based approaches. Because smartphones are a relatively novel mechanism of health information delivery and behavioral intervention, there is little evidence on how smartphone technology is being leveraged to prevent unintended pregnancy.

Mobile phone apps have rapidly expanded in scope, sophistication, and reach, presenting a unique opportunity to put tools for pregnancy prevention in the pockets of millions of Americans. Although health-related apps proliferate, there is no evidence that evaluates how they are being used to prevent pregnancy. Our research team conducted a systematic review of smartphone apps to answer the following questions:.

What types of apps are currently available for family planning and pregnancy prevention? Through what mechanisms are these apps preventing unintended pregnancy and are these approaches evidence-based?

What features of mobile technology are included in the user interface of these apps? Who are the intended users of these apps and what is their feedback on these apps?

In September , we developed a comprehensive set of 30 search terms by using Medical Subject Headings terms and by consulting with researchers leading 2 other ongoing reproductive health systematic reviews. We also developed the following set of inclusion and exclusion criteria:.

App includes or advertises at least one component of pregnancy prevention or decision-making such as the following: fertility information ie, charting, information, etc that claims to help prevent pregnancy; birth control reminders that claim to help prevent pregnancy; contraception information that explicitly notes pregnancy prevention; pregnancy decision-making information; sexual communication or negotiation information focused on preventing pregnancy.

App is for personal use by individuals looking to make decisions about their pregnancy ie, not for clinicians, researchers ;. To be included in the review, the app had to either explicitly state that it could help prevent unintended pregnancy or have content that supported unintended pregnancy prevention or decision-making, such as information on how to negotiate safe sex, clarification of pregnancy intention, or information about birth control.

We therefore wanted to assess the information provided at this key juncture. Similarly, we included pregnancy test apps that may not have a primary purpose of preventing unintended pregnancy but may be the first point of access for individuals whose contraceptive method has failed and, regardless of whether they are pregnant, may be in need of improved family planning or contraceptive counseling.

While most apps were indeed free, we did not limit the review to free apps because we also wanted to assess whether there were significant quality differences between paid and unpaid apps.

Additionally, paid apps that advertised the same services as their free counterparts were excluded to avoid duplication. Each search term was put into both the iTunes store and Google Play store search engines and the resulting number of app descriptions was recorded for each search term see Appendix I for search terms and search engine results. All app descriptions were screened for relevance based on the inclusion criteria; however, because of the high number of returned app descriptions and there being no way to export the app descriptions into a spreadsheet, only apps that met inclusion criteria were documented.

Therefore at the app description review level, we were unable to document the individual reasons for the exclusion of apps. The codebook and data extraction form were finalized using examples from ongoing systematic reviews, as well as sources of pregnancy prevention best practices [ 15 - 17 ]. We established 3 broad domains— 1 pregnancy prevention best practices, 2 contraceptive information and clinical services, and 3 user interface—and data extraction points were created in each domain.

Additional purpose-specific questions were developed once the primary purpose categories for all apps were finalized. Purpose-specific questions were developed for the young adult sexual and reproductive health information apps, birth control reminders, and fertility tracking apps in order to capture the nuances of these particular pregnancy prevention strategies.

In total, the codebook included data extraction points for every app, plus up to an additional 15 purpose-specific data extraction points. Data extraction occurred in November In this study, 2 researchers with iPhones were assigned to iTunes and 2 with Android phones to Google Play. To answer the first research question about what types of apps are in the family planning space, apps were categorized by their perceived primary purpose eg, birth control reminders, fertility trackers, etc.

Categorization was done on an iterative basis as the app descriptions were reviewed in the stores and was finalized by the team during the data extraction phase when content was reviewed in depth.

Apps were assigned only to 1 category. We used 3 methods to evaluate the mechanisms through which the apps attempted to prevent unintended pregnancy and their use of evidence-based approaches. After a thorough review of PubMed and the gray literature, we identified a recent evidence-based clinical practice guideline for the prevention of unintended pregnancy that incorporated interventions for pregnancy prevention and evidence from federal and non-governmental programs into a comprehensive framework for unintended pregnancy prevention [ 16 ].

These guidelines provide a full spectrum of essential primary, secondary, and tertiary prevention services, including:. Primary: Assessment of personal and family health risk factors for unintended pregnancy including intimate partner violence and substance abuse , appropriate screening tests, and prevention services;.

Secondary: Assessment of pregnancy status, options counseling, support to continue pregnancy, and early abortion care; and. We further distilled these guidelines into the 7 pregnancy prevention best practice queries below, which either directly prevent unintended pregnancy P1, P2, P4, P5, P7 or potentially lead to support for the termination of a current pregnancy or the prevention of future unintended pregnancy P3, P6.

We assessed each app for the inclusion of these 7 items, assigning 1 point per included item for total possible score ranging between 0 and 7. We also assessed whether the app described how to use the contraceptive method, and whether the app provided information on the effectiveness of the contraceptive method.

Finally, we evaluated whether the app provided information on where to access any contraceptives eg, at a clinic, a pharmacy, a grocery store , whether the app located any contraceptives near the user, whether the app provided any information on contraceptive risks or side effects, whether the app included any information on side effect management or switching contraceptive methods, and whether the app discussed dual protection ie, prevention of both pregnancy and sexually transmitted infections STIs.

Third, we quantitatively scored each app using 2 scores: 1 the first based on the total number of desirable features interface and content included out of 84 possible features and 2 the second score based on the number of contraceptive methods out of the 14 noted above and the number of 7 possible pregnancy prevention best practices included in the app possible score of 21; see Appendix III.

We qualitatively described any innovative or useful features in the top-scoring apps. If the app provided a clear overall message about how to avoid unintended pregnancy, it was weighted to receive 10 points. Answering the third research question about which features of smartphone technology were represented was done with consultation from an app development specialist who helped clarify and define the different components of smartphone user interface. We also evaluated apps for the presence of 4 undesirable components of interface, including whether the app crashed during review, whether navigational links were broken, whether there was advertising, and whether the app required purchase after being downloaded in order to use the basic features advertised in the free version.

Demographic information about app users was not publicly available, so we devised a methodology to answer this research question based on the images in the apps. We also reviewed for gender-targeting.

Apps were deemed to be targeting females if it was explicitly stated or if the apps only provided services that are relevant to a female such as tracking her own menstrual cycle. Apps were deemed to be targeting males if the app only provided male sexual or reproductive health information.

In terms of age, we reviewed for general versus young adult targeted apps. Finally, we conducted an overall analysis on user ratings and downloads. Of these, unique apps met inclusion criteria and were included in the review in iTunes, 93 in Google Play, and 24 listed in both.

See Appendix II for full list of included apps. Apps that were available in both iTunes and Google Play were removed from the iTunes group and only analyzed as Google Play apps to avoid duplication. The largest category, fertility trackers, included apps that explicitly advertised that they could help women prevent pregnancy by assisting the user with fertility awareness-based methods of family planning, also called natural family planning.

Fertility trackers mostly utilized user-provided information about menstrual cycles and cervical biomarkers to predict when a woman would or would not be fertile. It is important to note that fertility tracking is more commonly used by those trying to become pregnant and these apps could be used for that purpose as well.

No fertility tracking apps we identified were exclusively designed for the purpose of preventing pregnancy.

The third largest category, birth control reminders, explicitly advertised pregnancy prevention. Birth control reminder apps generally used visual cues such as blister packs or calendars, push reminders, and alarm features to remind the user to take their birth control.

Birth control methods supported by these reminders were mostly daily oral contraceptives, but a few were for alternative contraception, including the ring NuvaRing , the patch, and the shot Depo-Provera. Other categories included apps that provided general SRH information and apps that provided SRH information in a more targeted manner to young adults.

We also identified groups of apps that primarily provided contraceptive method information, typically as a descriptive list of types of contraceptives; apps that were for the purpose of locating SRH services or condoms using GPS features; pregnancy tests, which collected information about biological and behavioral user experience; and educational games. Behavioral contraceptive counseling, defined as persuasive counseling that recommends or describes the importance of contraceptives, was also infrequently included.

The most common evidence-based pregnancy prevention method in apps—referral to pregnancy testing—was offered by less than a third of all apps. When we analyzed the presence of best-practices by app primary purpose, we found that YA SRH apps integrated the highest percentage of overall best practices into their services offered, followed by center and resource apps and general SRH information apps Table 1. Fertility tracking apps, birth control reminder apps, and pregnancy test apps incorporated the fewest best practices for preventing unintended pregnancy.

Percentage of mobile phone apps containing information about types of contraceptive methods, their effectiveness, and use. SRH information, YA SRH information, and contraceptive information app categories had the greatest number of individual apps that mentioned the largest number of contraceptive methods.

On average, apps in each of these 3 categories mentioned 7 contraceptive methods and were also more likely to mention the effectiveness of the contraceptive methods, compared with other app categories. Birth control reminders rarely mentioned the use of contraceptive methods other than the particular method that app was promoting, even if the user entered data showing poor adherence. Notably, only 1 of 35 birth control reminder apps included any information on contraceptive side effects or switching.

There was a strong correlation 0. Of the 6 top-scoring apps, 1 app was on YA SRH information, 4 were general SRH information, 1 app was from the contraceptive information category, and 1 from the centers and resources category. In addition to the contraceptive information and pregnancy prevention best practices features, these apps included features like GPS, push notifications, decision aids, a clear description of how to avoid unintended pregnancy, information on dual protection and STIs, and many other of the 84 attributes that contribute to user experience and support the prevention of unintended pregnancy.

In this study, 5 of the 11 top-scoring apps were developed in the United States and 4 were developed in the United Kingdom. In addition to the quantitative scoring, reviewers also wrote brief descriptions of the apps, including notable features or problems. Among the highest-scoring apps, there were several features that are worth highlighting.

The Mayo Clinic: About Birth Control app included a useful interactive decision aid that guided users to a contraceptive method that was a good fit for them based on a series of questions about pregnancy intentions, health conditions, personal habits, privacy requirements, and general preferences. This app also provided helpful videos, pictures, and a glossary of contraceptive information.

A useful feature in the My Sex Doctor Lite app is a series of questions that lets young adults explore whether they are in an abusive or controlling relationship.

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