Quantity over quality-Findings from a systematic review and environmental scan of patient decision aids on early abortion methods

User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study

BACKGROUND

People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive-there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices.

OBJECTIVE

We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

METHODS

We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers' decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy ("patient" participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses.

RESULTS

A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly.

CONCLUSIONS

We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

Factors Influencing Abortion Decision-Making of Adolescents and Young Women: A Narrative Scoping Review

INTRODUCTION

Globally, about half of all induced abortions have been estimated to be unsafe, which results in 13% of maternal deaths yearly. Of these induced abortions, 41% of unsafe abortions have been reported in young women who are dependent on their parents for their livelihood. They are often left in a vulnerable position and may have difficulty in making a decision regarding abortion. This study aimed to (1) characterize and map factors that influence abortion decision-making of adolescents and young women, and (2) identify the care and support that they need in their decision-making process.

METHODS

We conducted a scoping review following the JBI method and PRISMA-ScR checklist. We comprehensively searched MEDLINE (PubMed), Embase, Cochrane Library, CINAHL, and PsycInfo, and hand searched publications in the Google Scholar database between November 2021 and October 2023. The search included all English language qualitative and mixed methods research articles published on the database up to October 2023 that included participants aged 10-24 years. The CASP checklist was used as a guide for the qualitative analysis. NVivo was used to synthesize the findings.

RESULTS

There were 18 studies from 14 countries (N = 1543 young women) that met the inclusion criteria. Three domains and eleven categories were included as follows: personal (desire for self-realization and unwanted pregnancy), interpersonal (parental impact, reaction of partner, roles of peers and friends, existence of own child, and lack of support), and social circumstances (sexual crime, financial problem, limitation of choice, and underutilized healthcare services). Decision-making factors regarding abortions were also found across all three domains.

CONCLUSION

The abortion decision-making of young women is influenced by various external factors regardless of country. Parents are especially influential and tend to force their daughters to make a decision. Young women experienced suffering, frustration, and lack of autonomy in making decisions based on their preference. This emphasizes the importance of autonomous decision-making. In this regard, healthcare services should be used. However, there are barriers to accessing these services. To improve such access, the following are required: staff training to provide adolescent and youth-friendly health services, counseling based on women's needs, counseling including the parents or guardians that is confidential and ethical, promotion of decision aids, and affordable accessible care.

Free Online Decision Tools to Support Parents Making Decisions About Their Children's Chronic Health Condition: An Environmental Scan

BACKGROUND

Medical decisions parents make on their children's behalf can be challenging. Free online decision support tools are created to help parents faced with these decisions.

OBJECTIVE

We used an environmental scan to identify free, online tools that support parents in making decisions about their children's chronic health condition. We described the tools and assessed their potential to harm, content, development process, readability, and whether their use changed decision makers' knowledge and alignment of their preferences with their final decision.

DATA SOURCES AND ELIGIBILITY

Decision aid repositories, Google searches, and key informants identified decision support tools. Eligible tools were freely available online and for parents of children with chronic health conditions.

APPRAISAL METHODS

Two reviewers independently assessed the tools' quality based on the International Patient Decision Aid Standards (IPDAS). Tool readability was assessed using the Flesch Reading Ease test.

RESULTS

From 21 free, online decision support tools, 14 (67%) provided sufficient detail for making a specific decision (IPDAS qualifying criteria). None sufficiently met IPDAS certification criteria necessary to reduce the possibility of patient harms when using the tool. Three (14%) were fairly easy or easy to read. Of those evaluated by developers (n = 6), 2 improved knowledge and 4 improved alignment of preferences with the available options.

LIMITATIONS

Google searches and key informant sources are not replicable.

CONCLUSIONS

Free, online decision support tools for parents of children with chronic health conditions are of variable quality, most are difficult to read, and there is limited evidence their use achieves intended outcomes.

REGISTRATION NUMBER

Registered with Open Science Framework 20 July 2021(AEST) osf.io/b94yj.

Woman and girl-centred care for those affected by female genital mutilation: a scoping review of provider tools and guidelines

BACKGROUND

A woman and girl centred, rights-based approach to health care is critical to achieving sexual and reproductive health. However, women with female genital mutilation in high-income countries have been found to receive sub-optimal care. This study examined documents guiding clinicians in health and community service settings in English-speaking high-income countries to identify approaches to ensure quality women and girl-centred care for those with or at risk of female genital mutilation.

METHOD

We undertook a scoping review using the integrative model of patient-centredness to identify principles, enablers, and activities to facilitate woman and girl-centred care interactions. We developed an inclusion criterion to identify documents such as guidance statements and tools and technical guidelines, procedural documents and clinical practice guidelines. We searched the databases and websites of health professional associations, ministries of health, hospitals, national, state and local government and non-government organisations working in female genital mutilation in the United Kingdom, Ireland, Canada, The United States, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation tool was used to appraise screened documents.

FINDINGS

One-hundred and twenty-four documents were included in this scoping review; 88 were developed in the United Kingdom, 20 in Australia, nine in the United States, three in Canada, two in New Zealand and two in Ireland. The focus of documents from the United Kingdom on multi-professional safeguarding (62), while those retrieved from Australia, Canada, Ireland, New Zealand and the US focused on clinical practice. Twelve percent of the included documents contained references to all principles of patient-centred care, and only one document spoke to all principles, enablers and activities.

CONCLUSION

This study demonstrates the need to improve the female genital mutilation-related guidance provided to professionals to care for and protect women and girls. Professionals need to involve women and girls with or at risk of female genital mutilation in the co-design of guidelines and tools and evaluation of them and the co-production of health care.

Access experiences and attitudes toward abortion among youth experiencing homelessness in the United States: A systematic review

Objectives

We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States.

Methods

We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options.

Results

Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences.

Conclusions

Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

[Women's emotional accounts of induced abortion]

OBJECTIVE

To explore women's emotional accounts of induced abortion, analyzing qualitative scientific publications.

METHOD

Qualitative systematic review of 19 studies published in PubMed, Science Direct and Scopus from 2010 onwards. The articles based on qualitative research design were revised using inductive content analysis.

RESULTS

The analysis identified three main themes regarding women's emotional experiences: access to abortion, emotional impact during medical assistance, and individual, relational and sociocultural determinants. The studies showed the variability in women's emotional accounts, mainly determined by the following factors: Access and waiting times, health system, type of intervention, degree of awareness and participation regarding the use of technical and medical technologies, interaction with health professionals, and specificity of individual, relational and sociocultural context. The main emotional difficulties were related to the ethical conflict, the decision-making, the relation with the social and health system and stigma. As main facilitating aspects, women highlighted autonomy in decision-making and emotional support, while barriers referred to social rejection and negative messages perceived from the political, social and health system.

CONCLUSIONS

The emotional accounts around induced abortion depend on individual and relational factors, as well as on health assistance, all mediated by gender inequalities and bias. Improvements in health assistance refer to an integral and individualized attention, adapted to women's needs.

Promoting or Undermining Quality Decision Making? A Qualitative Content Analysis of Patient Decision Aids Comparing Surgical and Medication Abortion

OBJECTIVES

To understand, describe, and compare the content of patient decision aids on surgical and medication abortion, including 1) attributes used to describe each method, 2) approaches to clarify patients' values, 3) language used to describe each method, and 4) language used to frame women's decision-making role.

STUDY DESIGN

We analyzed 49 decision aids identified through a previous systematic review and environmental scan. We used summative content analysis for objectives 1 and 2 and directed content analysis for objectives 3 and 4.

RESULTS

We identified 37 method attributes. Overall, the attributes privileged medical over practical and emotional information. One decision aid included an explicit values clarification approach, and others included implicit approaches, which varied in length, information consistency, and organization. We identified four themes-information consistency, subjective claims, emotive or ambiguous descriptions, and medication abortion as not a real abortion-related to the methods' descriptions. We identified three themes-agency in choice, unclear emphasis on women's preferences, and endorsement of clinic services-related to women's decision-making role. Of the nine tools that listed factors influencing women's decision making, patient preferences was often listed last.

CONCLUSIONS

Early abortion method decision aids presented a broad range of information and typically framed the method choice as the woman's. However, their emphasis on medical attributes, use of inconsistent information, and, at times, biased presentation of methods may undermine quality decision making. We recommend adapting an existing decision aid or designing a novel tool based on the content and language that women find most acceptable.

Online Decision Aids for Knee Osteoarthritis and Low Back Pain: An Environmental Scan and Evaluation

Background. Musculoskeletal conditions are leading causes of disability. Management options are plentiful, but the current evidence base suggests many are ineffective or unproven. Online decision aids can help support patients make informed health care choices. However, there are little data on the quality of online decision aids for common musculoskeletal conditions such as knee or low back pain. Purpose. To identify all publicly available online decision aids for knee osteoarthritis and low back pain and evaluate them against the International Patient Decision Aids Standards Inventory (IPDASi). Data Sources. Google Australia. Study selection. Two reviewers independently screened websites for inclusion and assessed the quality of included online decision aids between April and May 2018. Included online decision aids were free, provided information about knee osteoarthritis or low back pain, and written in English. Online decision aids that required payment, targeted health professionals, addressed rheumatoid arthritis, or addressed a screening decision were excluded. Data Extraction. IPDASi Version 4. Data Synthesis. Twenty-five online decision aids were identified: 15 knee osteoarthritis and 10 low back pain. Only 3 online decision aids (12%) provided a “wait-and-see” option. Nineteen (75%) met IPDASi criteria to be considered a decision aid and 3 (12%) met IPDASi criteria to state that the online decision aid was unbiased. Limitations. Dynamic nature of Google searches may not be replicable easily. Conclusions. Few good-quality online decision aids are available for people with knee osteoarthritis or low back pain. Most online decision aids failed to explicitly provide a wait-and-see option, suggesting a bias toward intervention. These online decision aids would benefit from explicitly highlighting a wait-and-see option to support informed choice.

Quantity over quality-Findings from a systematic review and environmental scan of patient decision aids on early abortion methods

Background

The availability and effectiveness of decision aids (DAs) on early abortion methods remain unknown, despite their potential for supporting women's decision making.

Objective

To describe the availability, impact and quality of DAs on surgical and medical early abortion methods for women seeking induced abortion.

Search strategy

For the systematic review, we searched MEDLINE, Cochrane Library, CINAHL, EMBASE and PsycINFO. For the environmental scan, we searched Google and App Stores and consulted key informants.

Inclusion criteria

For the systematic review, we included studies evaluating an early abortion method DA (any format and language) vs a comparison group on women's decision making. DAs must have met the Stacey et al (2014). Cochrane review definition of DAs. For the environmental scan, we included English DAs developed for the US context.

Data extraction and synthesis

We extracted study and DA characteristics, assessed study quality using the Effective Practice and Organization of Care risk of bias tool and assessed DA quality using International Patient Decision Aid Standards (IPDAS).

Results

The systematic review identified one study, which found that the DA group had higher knowledge and felt more informed. The evaluated DA met few IPDAS criteria. In contrast, the environmental scan identified 49 DAs created by non‐specialists. On average, these met 28% of IPDAS criteria for Content, 22% for Development and 0% for Effectiveness.

Conclusions

Research evaluating DAs on early abortion methods is lacking, and although many tools are accessible, they demonstrate suboptimal quality. Efforts to revise existing or develop new DAs, support patients to identify high‐quality DAs and facilitate non‐specialist developers' adoption of best practices for DA development are needed.