The use of long-acting reversible contraceptives: a quasi-experimental study in Indonesia

Contraceptives can be used as a primary strategy to promote maternal and child health by allowing for sufficient birth spacing and avoiding unintended pregnancy (Tepper et al, 2020; United Nations Department of Economic and Social Affairs (UN DESA), 2020). Globally, approximately 49% of married women worldwide were using contraceptives in 2020 (UN DESA, 2020). In Indonesia, 44.4% of married women aged 15–49 years use contraceptives (UN DESA, 2020). Modern contraceptive methods are used by 97.4% of women, but only 21.6 % used long-acting reversible contraceptives in Indonesia (Center for Reproductive Health, 2015). Additionally, 24.7% have used family planning at least once, while 15.5% have never used contraceptives (Gafar et al, 2020). Notably, contraceptive use, especially long-acting reversible contraceptives, has direct health advantages for mothers and children, and prevents unintended pregnancy and subsequent declines in maternal mortality and morbidity (Tessema et al, 2021).

In healthcare terms, desirable behaviour (appropriate birth spacing) is more likely to occur if an individual intends to use long-acting reversible contraceptives, there are no environmental barriers and the individual possesses the necessary skills and ability to perform the behaviour (Gebremariam and Addissie, 2014). The intention to use a method of contraception that is effective, safe, reversible and long-acting needs investigating (Babalola et al, 2015; Daba et al, 2021). Specifically, the intention to use contraceptives is a critical indicator of future demand for family planning services (Abraha et al, 2018). An improved understanding of women's intentions to use contraceptives may provide additional insight into the demand for future use of long-acting, permanent contraception methods (Ahuja et al, 2020).

A barrier to increasing use of contraceptives is a low level of knowledge about the side effects of contraceptive drugs and equipment (Semachew Kasa et al, 2018; Gafar et al, 2020). In the absence of or inadequate use of contraceptives, a lack of knowledge of the fertility period can result in adverse health outcomes, including unintentional or unplanned pregnancy. Thus, adequate knowledge of the ovulatory phase or fertility can effectively reduce unintended pregnancy rates (Blackstone et al, 2017). Good knowledge of contraceptive effectiveness is associated with an increase in the use of long-acting reversible contraceptives, which have low failure rates when used as prescribed (Zegeye et al, 2021). Inadequate knowledge of contraception is associated with erroneous perceptions of its risks and side effects, ineffective or inconsistent use and method discontinuation (Pazol et al, 2015). Consequently, the impact of knowledge on the selection of and correct, consistent use of contraception makes contraceptive counselling of high importance.

Self-efficacy is an essential predictor of effective preventive health behaviours, including contraceptive use (Hamidi et al, 2018). Self-efficacy is an individual's belief in their capacity to affect their behaviour (Rosenstock et al, 1988). A previous study showed that Turkish women with a high self-efficacy score were significantly more likely to use contraceptives (Peyman and Oakley, 2011). Women with a high level of self-efficacy also used prescription contraceptives more frequently than non-prescription methods. However, there is a lack of research examining self-efficacy to make effective contraceptive choices (Peyman and Oakley, 2011; Kim et al, 2017; Hamidi et al, 2018). Contraceptive counselling has been recommended to increase self-efficacy (Kim et al, 2017).

Contraceptive counselling can assist women in selecting a method that meets their needs and preferences, managing side effects and sustaining or switching methods (Cavallaro et al, 2020). Critical components of high-quality contraceptive counselling include needs assessment, tailored communication and shared decision making (Cavallaro et al, 2020). The contraceptive health research of informed choice experience project assessed the effect of contraceptive counselling on the use of long-acting reversible contraceptives, such as an intrauterine device or implant, using novel contraceptive counselling, and found it was an important influence on this behaviour (Madden et al, 2013, 2018; Mazza et al, 2020). Interventions to reduce the rate of unplanned pregnancies in women are critical to improving maternal and neonatal morbidities and mortalities (Kopp et al, 2015; Cavallaro et al, 2020).

In clinical and community settings with limited counselling time, innovative approaches are needed to fill health promotion gaps (Hebert et al, 2018). Mobile applications have functionalities that may be suitable for these settings. The World Health Organization (WHO, 2019) has launched a mobile application to support its medical eligibility criteria for contraception use. This digital tool assists family planning providers in recommending safe, effective and acceptable contraception to women who have medical conditions or other medically significant characteristics, and is also suitable for use by patients. The app has been adapted to Bahasa Indonesia and verified by the Ministry of Health of the Republic of Indonesia (Kementerian Kesehatan Republik Indonesia, 2020).

Contraceptive counselling in combination with use of the app may positively escalate knowledge, self-efficacy and the intention to use contraceptives in married women. However, these relationships require clarification and no research has been conducted to explore the app's effect on knowledge, self-efficacy and contraceptive use among married Indonesian women. Therefore, the present study's aim was to investigate the synergistic effects of structured contraceptive counselling and use of the Indonesian version of the WHO app on knowledge, self-efficacy and long-acting reversible contraceptive use among Indonesian women.

Methods

This quasi-experimental clinical trial was conducted from June to September 2022 at two healthcare centres with family planning services in Langsa, Aceh Province, Indonesia. The healthcare centres are managed by a physician and midwife staff.

Participants

Convenience sampling was used to recruit women of childbearing age (15–49 years) as the target population. The inclusion criteria were those who were married, as in Indonesia unmarried women are not legally able to use contraceptives, lived in a given cluster in the district, were not pregnant, used an android device, as the intervention required the use of an android mobile application, and did not use long-acting reversible contraceptives. Participants who were infertile, severely ill or used antidepressants were excluded from the study.

Sample size

To determine the sample size for the repeated-measures analysis of variance, a power analysis was conducted using G*Power Version 3.1.2, with the power sample at 0.95, the effect size at 0.50 and the significance level set to 5% (Faul et al, 2007). A sample size of 54 patients was determined, 27 in each group (intervention and control). The study assumed a 50% attrition rate, and so 41 respondents were recruited to each group.

Intervention

Participants with even medical record numbers were assigned to the study group, while those with odd numbers were assigned to the control group. The intervention group received structured contraceptive counselling and were instructed to download the mobile contraceptive application. The control group received standard contraceptive counselling and did not use the app.

Structured counselling

The structured contraceptive counselling used in this research was based on the CHOICE project model. CHOICE is a client-centred and personalised counselling process involving three face-to-face sessions over 4 weeks (each session lasting approximately 30 minutes). The sessions cover information on contraceptive methods, and their effectiveness, advantages, disadvantages, risks and adverse effects. A demonstration box with contraceptive models is used, and proper use of contraception is explained, particularly long-acting reversible contraceptives.

The technique used by the counsellor followed a series of steps (Madden et al, 2013; Kaewkiattikun, 2017). Clients were greeted with a smile, politeness, warmth and respect, to establish a positive rapport between counsellor and client. The counsellor then inquired about the client's family planning requirements, informed the client of all available birth control methods, assisted the client in making the best choice, demonstrated how to use an approved form of birth control and scheduled a follow-up visit or visits to discuss any concerns.

The app

The mobile app, the ‘WHO contraceptive tool’, included content on all methods of contraception, including images of each technique, information on side effects and effectiveness rates, information about family planning services and an online version of the medical eligibility criteria wheel for contraceptive use (Kementerian Kesehatan Republik Indonesia, 2020). The wheel includes recommendations on initiating use of nine common contraceptive methods: (1)

• Combined pills (low dose combined oral contraceptives, with ≤35μg ethinyl estradiol)
• The combined contraceptive patch
• The combined contraceptive vaginal ring
• Combined injectable contraceptives
• Progestogen-only pills
• Progestogen-only injectables (intramuscular or subcutaneous depot medroxyprogesterone acetate or intramuscular norethisterone enantate)
• Progestogen-only implants (levonorgestrel/etonogestrel)
• The levonorgestrel-releasing intrauterine device
• The copper-bearing intrauterine device.

The app could be used repeatedly regardless of location, and participants were able to access the app over the 4 weeks of the counselling programme.

Data collection

Data were collected at three time points: baseline (T0), 4 weeks after the intervention began (T1) and 12 weeks after (T2). The questionnaires contained three parts: participants' sociodemographic characteristics, knowledge of contraceptives, one on self-efficacy and one on the intention to use contraceptives.

Before the intervention, participants in both groups completed the questionnaires. Then the participants who received the intervention were encouraged to look through the information on the mobile app and given 10–15 minutes to engage with it. They also received a contraceptive consultation with a physician and midwife. The control group completed the online survey and moved directly to a routine clinic visit, which did not include structured contraceptive counselling. All participants completed follow-up questionnaires at 4 (T1) and 12 weeks (T2). Follow-up data were collected by telephone to reduce missing data or data loss from lack of follow-up and participants were encouraged to attend the clinic visit at 4 and 12 weeks. The questionnaires were distributed electronically and completed by participants on a smartphone accompanied by enumerators.

Translating and validating the questionnaire

The questionnaires were translated from English into Indonesian. Two nursing communities independently translated the questionnaires from English to Bahasa Indonesian. These three translations were combined and back-translated into English by another professional translator and native Indonesian speaker, who had no prior knowledge of the instruments.

The questionnaire was validated by experts, to ensure that the questions contained valid content and were acceptable and readable. Specific modifications were made in response to the feedback received to facilitate comprehension of the questions. The content validity index was used to verify the construct's integrity (Wild et al, 2005). A draft of all questions was sent to a panel of three experts from Sekolah Tinggi Ilmu Kesehatan Yogyakarta and the Institut Ilmu Kesehatan Bhakti Wiyata Kediri. The experts had all worked in fields related to the subject of the study for at least 4 years, and included two family planning specialists and a midwife health community expert.

For knowledge of contraceptives, the Indonesian version of the instrument had a Cronbach's alpha of 0.77. According to three nursing experts, the content validity value was 0.80. For self-efficacy, the Indonesian version of the instrument had a Cronbach's alpha of 0.93 and the content validity value was 0.90.

Questionnaire contents

The sociodemographic characteristics collected were age, employment status (unemployed or employed), education (international standard classification of education; <3, ≥3), income (low or high, based on whether income was above or below the regional minimum wage), parity (none, 1 or ≥2 births), past contraceptive use (non-use, condoms, birth control pills or depot medroxy progesterone acetate).

Contraceptive knowledge was assessed using a 25-item questionnaire. The questions included ‘which birth control method is the only method that helps prevent infections?’ and ‘which method of birth control is the best at preventing pregnancy?’. Each item on the multiple-choice assessment had five possible responses, except item 21, which had six. One point was awarded for a correct response and none for an incorrect response (Haynes et al, 2017).

To determine self-efficacy, three items were assessed. Participants were asked: ‘how confident are you that you can consult with your physician or midwife about the best method(s) of birth control to use’, ‘do you use birth control properly to avoid pregnancy?’ and ‘do you have the necessary information to select the most appropriate method of birth control for you?’. The total score for each item ranged from 0–10, with higher scores indicating higher self-efficacy (Tebb et al, 2021).

Respondents' behavioural intentions (whether or not to use contraception) were assessed by asking individuals to rate the likelihood of using two long-acting reversible contraceptives, an intrauterine device and the implant, in the future on a 5-point Likert scale (1=not likely at all, 5=absolutely). This instrument was modified from previous studies (Hebert et al, 2018; Tebb et al, 2021). A higher score indicated a more favorable attitude towards using contraceptives.

Data analysis

Data were imported to the statistical package for social sciences (version 25.0) for analysis. The mean (standard deviation) and frequency were used to identify continuous and categorical data. Chi-squared and one-way analysis of variance tests were used to compare sociodemographic and baseline characteristics between the two groups. Generalised estimating equation models, with appropriate link functions and distribution assumptions, were used to compare differential changes in outcomes over time and between groups, with adjustments made for potential confounding variables. For all tests, P<0.05 was considered statistically significant. Missing data (n=1 changed place of residence to a different district in the intervention group) at follow-up were assumed to be missing at random, and data were analysed on an intention-to-treat basis.

Study fidelity

The study fidelity was established through meetings with investigators, midwives, enumerators and physicians to review protocols, check proficiency measurements and equalise perceptions during the survey. Counsellors, including midwives and physicians, used the protocol study with a standardised WHO contraceptive counselling guide. All participants' medical records were reviewed to assess which contraceptive method, if any, they chose after their last clinic visit. The authors called participants who registered to encourage them to go to the clinic and fill out follow-up surveys 4 and 12 weeks after the intervention.

Ethical considerations

The study protocol was approved by the Ethics Committee Board of Universitas Sumatera Utara (approval number: IRB: 2320/VI/SP/2021) and was in accordance with the provisions of the Declaration of Helsinki. After receiving both verbal and written information about the study, each participant was asked to sign a consent form, indicating that they had read and understood the information and agreed to participate.

Results

Participants' baseline sociodemographic characteristics are shown in Table 1. participants' mean ages were 31.4 years for the study group and 32.3 years for the control group. Most of the participants did not use contraceptives and had a parity of one. No statistically significant differences between the two groups were noted in sociodemographic or clinical characteristics.

The scores for knowledge, self-efficacy and intention to use long-acting reversible contraceptives before and after the intervention are shown in Table 2 and Figure 1. Participants in both groups had increased scores in all areas after 4 and 12 weeks.

A comparison of knowledge, self-efficacy and intention scores between groups is shown in Table 3. The differences in knowledge (P=0.797), self-efficacy (P=0.931) and intention to use contraceptives (P=0.839) between groups at baseline were not statistically significant. There was a significant increase in knowledge after 4 and 12 weeks for both groups (P<0.001). The effect of the intervention was significant, as the increase in the intervention group was significantly higher than the control group (P<0.001). The intention to use long-acting reversible contraceptives increased significantly after 4 and 12 weeks in both the control and intervention group (P<0.001). There was a significant difference between groups after 4 and 12 weeks (P<0.001).

Discussion

In this quasi-experimental study, a combination of structured contraceptive counselling and use of a mobile app was found to result in increased prevalence of the intention to use long-acting reversible contraceptives, as well as increased knowledge and self-efficacy for married women in Indonesia. It has previously been reported that independent mobile contraceptive apps and face-to-face counselling can help increase knowledge and the intention to use long-acting reversible contraceptives (Hebert et al, 2018). The present study's results are consistent with a preliminary study in Chicago, which revealed that patients' knowledge of contraception and interest in long-acting reversible contraceptives improved as a result of mobile app use (Gilliam et al, 2014a). The present study used the mobile app as a clinical complement to address issues and problems raised by women that may not be handled in routine counselling, alongside images of each technique, information on side effects and effectiveness rates and information about family planning services.

Mobile apps on contraceptives may hold promise for improving women's knowledge and self-efficacy and promoting the intention to use long-acting reversible contraceptives (Tebb et al, 2021). Mobile apps allow users to navigate and choose relevant information (Sridhar et al, 2015), rather than relying on paper pamphlets. Patients are able to conveniently use a mobile app that provides information, avoiding the potential issue of long waiting times at clinics (Gilliam et al, 2014b; Hebert et al, 2018).

However, two randomised controlled trials (Gilliam et al, 2014a; Sridhar et al, 2015) conducted in Chicago and California previously reported that app use alone does not influence the choice of long-term contraceptive method. Similarly, a previous study among African American and Latina women aged 15–24 years showed no change in self-efficacy for contraception during the study period compared to the control group (Akinola et al, 2019). It is possible that these results differ from the present study's because more engagement with mobile apps, through either a more extended intervention period or additional refresher sessions in the interim, can significantly facilitate modification of perceptions (Sridhar et al, 2015; Akinola et al, 2019). Additionally, the intervention in the previous studies consisted solely of use of the mobile app and did not include face-to-face counselling, which may contribute to lower self-efficacy (Tebb et al, 2021).

Contraceptive counselling improves uptake of use (Dehlendorf et al, 2014, 2016; Cavallaro et al, 2020), but some research has found it does not have an impact (Langston et al, 2010). There is a need for improved study reporting and the development and evaluation of novel intervention strategies (Langston et al, 2010; Secura et al, 2010). Structured counselling on contraceptives based on the CHOICE project was a novel counselling method designed to improve long-acting reversible contraceptive use (Madden et al, 2013, 2018; Mazza et al, 2020). Consequently, the synergistic effect of counselling with mobile app use, combining a consultation with learning at home, may be an ideal complement to brief clinical visits, which may not allow sufficient time for comprehensive contraceptive counselling. The mobile app also allows patients to review trusted health information prior to seeing their physician. This may be helpful for both physicians and patients, as it provides additional health education material for use in their consultations (Akinola et al, 2019).

Strengths and limitations

The present study's use of a synergistic effect is one of its strengths. It is the only study to examine the effects of both structured counselling and mobile apps on knowledge, self-efficacy and long-acting reversible contraceptives use in Indonesian women. This study is also relevant as previous research on long-acting reversible contraceptive use was minimal in Indonesia. The present study, conducted in two community health centers in the Langsa district, highlights health policy challenges related to contraceptive use.

Although determining the immediate effects of a 12-week treatment is essential, as was done in the present study, long-term follow-up evaluation is also required. Additionally, the present study did not investigate the potential impact of differences in research on partner support. In future research, exploring and controlling for a husband's support by applying statistical techniques to groups at random should be conducted. Moreover, causality could not be established because of the study's quasi-experimental design.

Conclusions

To the best of the authors' knowledge, this is the first study to investigate the synergistic effect of structured counselling and mobile app use on knowledge, self-efficacy and long-acting reversible contraceptive use in Indonesian women. The results suggest that midwifery educators and health professionals could play a prominent role in promoting strategies that improve women's knowledge, self-efficacy and contraceptive use by integrating structured contraceptive counselling and mobile apps into standard practice.

Key points

• Lack of knowledge and low self-efficacy can lead to the non-use of contraceptives among married women in Indonesia.
• Counselling and mobile applications are critical interventions to reduce the number of unplanned pregnancies, and can be used to complement standard care.
• The combination of structured counselling and mobile apps can effectively increase women's knowledge, self-efficacy and intention to use long-acting reversible contraceptives.

CPD reflective questions

• Do you think the combination of structured counselling and mobile apps could be implemented in contraceptive use programmes?
• What can midwives do during routine practice to encourage knowledge, self-efficacy and the intention to use long-acting reversible contraceptives?
• How can healthcare organisations ensure married women have good knowledge and self-efficacy to assist in preventing unintended pregnancy?