Strategies to improve adherence and acceptability of hormonal methods of contraception

 

Abstract

Background

Worldwide, hormonal contraceptives are among the most popular reversible contraceptives in current use. Despite their high theoretical effectiveness, typical use results in much lower effectiveness. In large part, this disparity reflects difficulties in adherence to the contraceptive regimen and low rates for long-term continuation.

Objectives

To determine the effectiveness of ancillary techniques to improve adherence to, and continuation rates of, hormonal methods of contraception.

Search methods

We searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, LILACS, PsycINFO, ClinicalTrials.gov and ICTRP.

Selection criteria

We included randomized controlled trials (RCTs) of an intensive counseling technique or client-provider intervention versus routine family planning counseling. Interventions included group motivation; structured, peer, or multi-component counseling; and intensive reminders of appointments or next dosing. Outcome measures were discontinuation, reasons for discontinuation, number of missed pills and on-time injections, and pregnancy.

Data collection and analysis

The primary author evaluated all titles and abstracts from the searches to determine eligibility. Two authors independently extracted data from the included studies. With RevMan, we calculated the odds ratio for all dichotomous outcomes and the mean difference for continuous data. The studies were so different that we did not conduct a meta-analysis.

Main results

We found eight RCTs; only one showed a statistically significant benefit of the experimental intervention. In that trial, women who received repeated, structured information about the injectable contraceptive depo-medroxyprogesterone acetate (DMPA) were less likely to have discontinued the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than were women who had routine counseling. The intervention group was also less likely to discontinue due to menstrual disturbances (OR 0.20; 95% CI 0.11 to 0.37). In another study, the intervention group was less likely to discontinue due to dissatisfaction with the contraceptive method (OR 0.61; 95% CI 0.38 to 0.98), but overall continuation was not affected.

Authors' conclusions

Most studies to date have shown no benefit of strategies to improve adherence and continuation. These trials have important limitations, however. Three had small sample sizes, four had high losses to follow up, and the intervention and its intensity varied across the studies. High-quality research is a priority, since adherence and continuation are fundamentally important to the successful use of hormonal contraceptives.

 

Plain language summary

Ways to improve use of hormonal birth control

Hormonal types of birth control are used by many women worldwide. The most common hormonal methods are birth control pills and injections. These methods often do not work as well as they could. Women may have problems using the birth control as planned. They may miss taking some pills. Other women may stop using a method due to bleeding changes. This review looked at whether more counseling helped women use these types of birth control.

We did computer searches for randomized trials comparing special counseling with usual counseling. In addition, we looked at reference lists to find trials. We also wrote to researchers to find more studies.

We found eight trials of moderate or low quality. Three trials had few women in them and four lost many women during the study. Six studies counseled women about the method and its side effects. Two trials focused on reminders for appointments or pill-taking. Only one trial of counseling found an important result. That study gave repeated, structured facts about an injected type of birth control. More of the women who got the structured facts kept using the birth control than the women who had the usual counseling. Also, fewer women who had the structured facts stopped using the birth control due to bleeding changes.

To prevent pregnancy, the birth control should be used as planned and the woman should keep using it. More trials of good quality are needed to see if more counseling helps women use their birth control method.

 

摘要

背景

改善荷爾蒙避孕方法之遵從性 (adherence) 和接受度(acceptability) 的策略

全世界來說，荷爾蒙避孕藥是現行最普遍的可逆式避孕方法。雖然它們理論上的有效性很高，但是實際使用上的有效性卻低的多，這樣的差異主要是因為對於荷爾蒙避孕藥的遵從性低，而且長期持續使用的機率低。

目標

探討輔助方法是否真的有效改善荷爾蒙避孕法的遵從性和持續使用率 。

搜尋策略

我們從電腦資料庫選取隨機對照試驗,去比較 “使用者提供者介入策略” 和傳統的家庭計畫諮詢。資料來源包括CENTRAL, MEDLINE, EMBASE, POPLINE, LILACS和PsycINGO。

選擇標準

針對積極諮詢技巧或 “使用者提供者介入策略” 和一般家庭計畫諮詢做比較的隨機對照試驗。介入策略包括: 團體動機強化; 結構化、同儕化或者多元化的諮詢方式; 預約回診加強提醒。紀錄的結果包括中斷人數、中斷的理由、漏掉的避孕藥量、及時注射 (ontime injection) 和懷孕。

資料收集與分析

原作者評估所有搜尋到的標題和摘要以檢視是否合格。兩個作者獨立作業從囊括的研究中取得數據。用RevMan 4.2計算所有雙向結果 (dichotomous outcomes) 的odds ratio，針對連續變相則計算其加權平均數。這些研究之間的差異太大以致於我們無法做出metaanalysis。

主要結論

我們找到6個隨機對照試驗，只有一個試驗顯示實驗的介入方法有顯著的好處。在這個試驗中，針對接受注射式避孕藥depomedroxyprogesterone acetate (DMPA)不斷獲得重複的、結構化的資訊的那些婦女，比起只得到一般諮詢的婦女，12個月內中斷治療的比率較低(OR 0.27; 95% CI 0.16 to 0.44)。實驗組也比較不會因為不規則經期而中斷治療。在另一個試驗當中，實驗組比較不會因為對於避孕方式的不滿意而中斷治療，但是整體的持續度並沒有受到影響。

作者結論

大多數的實驗顯示額外的介入策略對於改善遵從性和持續使用率並沒有幫助。然而這些實驗有重大的限制。其中兩個研究個案樣本數量小，其中數個研究中斷追蹤的比率高，而且介入策略的種類和其強度在各個研究之間有很大差異。品質良好的研究是優先需要的，因為遵從性和持續使用率是荷爾蒙避孕藥成功使用的關鍵。

翻譯人

本摘要由臺灣大學附設醫院黃楚珺翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

荷爾蒙避孕法是現行世界上最普遍的可逆式避孕法。雖然它們理論上的有效性高，但是一般典型的使用方法下有效性卻低的多。大部分的因素來自於服用避孕藥的遵從率低而且持續使用的機率也低。這篇回顧的目的是要探討加強醫療諮詢是否可以改善荷爾蒙避孕法的遵從性和持續度。我們檢視關於幫助婦女使用荷爾蒙避孕的隨機對照試驗。6個被選取的試驗品質不一。其中2個試驗樣本數量小，而其中數個試驗中斷追蹤的比率高。只有一個試驗顯示結構化的醫療諮詢有顯著的好處。那些反覆接受結構化資訊的婦女，比起其他接受一般諮詢的婦女，一年後持續使用注射式荷爾蒙避孕的比率較高。此外，接受結構化諮詢的婦女也比較不會因為經期上的變化而停止使用避孕藥。為了避免非計畫中的懷孕，持續使用且遵從正確的避孕藥服用方式是重要的。我們需要更多品質優良的試驗去評估加強醫療諮詢是否可以改善荷爾蒙避孕藥的使用。