
Counseling approach

The structure of the counseling session guided by the app is not fundamentally different than the accepted best practices used around the world. The main innovation it brings to FP counseling is a small but important paradigm shift with respect to shared decision-making: The app uses an algorithm to internally rank methods from most to least suitable for each client using her elicited goals and preferences. In the established, or status quo, approach to counseling, these tailored rankings are not revealed to the client (nor to the provider): Instead, the client is given information about all contraceptive methods and asked to choose the method she would like to discuss. The counselor is expected to provide no guidance or advice during this IDM process. In our alternative approach, the app encourages SDM by revealing the top-ranked method for the client according to the app’s internal algorithm with the nurse counselor proposing to discuss that method first. To test the effectiveness of this approach against the status quo, clients were randomly assigned to IDM or SDM with equal probability:1) IDM: The tablet displays all available modern contraceptive methods that have not been ruled out by the client or contraindicated due to medical eligibility. The provider gives basic information on each available method (in order of the methods displayed on the tablet screen, which is randomized) covering its use, duration, and typical use effectiveness. These quick descriptions are designed to take 1 to 2 min per method or 5 to 6 min overall. The counselor then asks the client which method she would like to discuss and provides detailed information with the help of the relevant cue card. The client can then either choose this method or discuss another one (of her choice from the same unranked list). This process is repeated until a decision is made. The app’s tailored ranking of methods is never revealed (the client does not know that there is an internal ranking).2) SDM: The tablet only displays the most suitable (top-ranked) method for the client according to the ranking algorithm of the app. The provider tells the client that “… while there are a number of suitable methods for her, based on their discussion, the displayed method is most suitable for her needs,” and asks her if she would like to discuss this method first. If the client answers “no,” then the next highest ranked method is displayed, and the process is repeated until the client decides to discuss the recommended method (or decline all of them). When the client answers “yes,” the provider uses the appropriate cue card to describe the method in detail. The client can then decide whether to choose this method (with an intent to adopt it) or discuss the next method recommended by the app. Again, this process is repeated until a decision is made.The randomization occurs toward the end of the consultation when the clients are ready to choose a method, after the discussion necessary for the client to make an informed choice and for the app’s internal algorithm to rank the methods has taken place, but before the random discounts are revealed. The counseling experiment aims to isolate the effect of informing the client that the app ranks all available methods according to their suitability for her needs, proposing to discuss them in this order of the rankings starting from the top, and revealing the methods one by one—rather than asking her to decide which method she would like to discuss from a list of unranked options.However, not everyone was randomly assigned to a counseling condition: slightly over half of the eligible clients visited the hospital seeking a specific method, which they either wanted to adopt or renew. The pilot phase preceding the study period had clearly revealed that such clients did not want, or need, to sit through a time-consuming session, where either all methods were summarized to them (IDM) or some discussed in detail (SDM). 