AN INTEGRATIVE REVIEW OF HOW PROVIDERS CAN USE TOOLS OR STRATEGIES TO SUPPORT SHARED DECISION-MAKING FOR CONTRACEPTIVE COUNSELLING IN PRIMARY CARE by Mercedes Ouellet B.H.Sc., University of Northern British Columbia, 2016 B.S.N., University of British Columbia, 2018 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING – FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA May 2025 © Mercedes Ouellet, 2025 ii Abstract Shared decision-making (SDM) is central component of patient-centered care and is of particular interest in contraceptive counselling, where a range of potentially suitable options are available, and personal preferences and values must guide clinical decisions. A systematic search was conducted in MEDLINE (via Ovid) and CINAHL to identify qualitative, quantitative, and mixed-methods studies published between 2019 and 2024. Inclusion criteria focused on studies evaluating SDM tools or strategies in clinic-based settings with women of reproductive age. Among the seven articles included in this review, a variety of SDM tools and strategies were used: decision aids, interview guides, provider prompts, and physical models. Key outcomes included improved patient satisfaction, decisional certainty, interpersonal quality of contraceptive counselling, perceived self-efficacy in decision-making and increased contraceptive knowledge. However, there was variability in how SDM was measured and whether outcomes were explicitly linked to SDM processes. Findings suggest that effective implementation of SDM tools or strategies in primary care practice may require a multifaceted approach involving both pre-visit patient tools and provider and patient supports during contraceptive counselling. Future research should seek to more clearly establish causal links between SDM strategies and outcomes, and to evaluate SDM tools or strategies in the Canadian context. iii TABLE OF CONTENTS Abstract ii TABLE OF CONTENTS iii List of Tables iv List of Figures v Glossary vi Acknowledgement vii Chapter One: Introduction and Background 1 Key Historical Developments in Contraception 2 Shared Decision-Making 4 Aim of Integrative Review 6 Chapter Two: Methods 7 Database Selection 7 Search Strategy 8 Critical Appraisal and Data Extraction 10 Chapter Three: Findings 11 Study Setting and Participants 12 Tools or Strategy Used 13 Study Design and Methodology 16 Outcomes and Applicability 17 Chapter Four: Discussion 22 Implications for Future Research 27 Implications for Practice 28 Chapter Five: Conclusion 31 References 32 Appendix 1: Search Strategy 38 Appendix 2: Prisma Diagram 39 Appendix 3: Integrative Literature Review Matrix 41 iv List of Tables Table 1: Key study characteristics 11 Table 2: Search terms and MESH headings 37 v Figure 1: PRISMA flow diagram List of Figures 38 vi Glossary DST Decision Support Tool IUD Intrauterine device LARC Long-acting Reversible Contraceptive NP Nurse Practitioner PHI CARE Past, Health history, Important, Counselling, Autonomy, Reviews, and Experience SDM Shared Decision-Making vii Acknowledgement Completion of this project would not have been possible without the expertise and guidance of my supervisor, Dr. Catharine Schiller. I am also deeply grateful to my partner Simon for his support, understanding and encouragement through all the stages of this work. 1 Chapter One: Introduction and Background Contraceptive use is a central component of reproductive and primary health care and has implications at both individual and population levels. The ability to choose when to have children has been linked to improved educational, economic, and social outcomes for women (Sonfield et al., 2013). Access to reliable contraception allows women to pursue higher education, participate more fully in the workforce, and attain greater economic stability (Sonfield et al., 2013). Lack of effective contraceptive options may lead to unintended pregnancies, which can have serious health, social, and economic consequences. Closely spaced pregnancies have been associated with increased risks of low birth weight, preterm birth, and maternal morbidity (Cleland et al., 2012). Unintended pregnancies are also more likely to result in delayed prenatal care and adverse social outcomes, including increased financial stress, educational disruption, and difficulties in securing housing and employment (Black, 2024). These challenges may disproportionately affect young women, those with lower socioeconomic status, and individuals who already face barriers in accessing health care. Over the past several decades, access to modern contraceptive options has improved significantly in many high-income countries, including Canada (Health Canada, 2024). Available modern methods of contraception which are covered by Medicare in Canada include oral contraceptives, copper and hormonal intrauterine devices (IUDs), injectable hormonal contraception, hormonal implants, and the vaginal ring (Health Canada, 2024). Increased access and uptake of modern contraceptive options has also coincided with notable demographic shifts. As of 2022, Canada’s fertility rate was 1.33 children per woman, the lowest rate recorded in the country’s history (Statistics Canada, 2024). The average age of mothers at childbirth has also risen steadily, from 26.7 years in 1976 to 31.6 years in 2022 (Statistics Canada, 2024). 2 According to the most recent data from the Canadian Community Health Survey (Carpino, 2025), approximately 73% of sexually active Canadian women aged 15 to 49 report using some form of contraception, with oral contraceptives and condoms being the most used methods, followed by IUDs. Despite the widespread availability of contraception and shifting demographics, unintended pregnancies remain common, with estimates suggesting that roughly 40% of pregnancies in Canada are unintended (Black, 2019). The public health costs associated with such pregnancies are estimated to be approximately $320 million annually (Black, 2019). The quality of contraceptive counselling, including the information provided and the degree to which the care provided is person-centered, is of increasing interest to researchers and health professionals (Brandi & Fuentes, 2020; Dehlendorf et al., 2017; Dicenzo et al., 2025). In this context, the use of shared decision-making (SDM) has developed as an important area of research in the realm of contraceptive counselling (Dehlendorf et al., 2017; Silva et al., 2022). Simply put, SDM refers to a decision-making process for a course of treatment in which both patient and provider share values, goals and information relevant to reach a consensus on the best option (Makoul & Clayman, 2006). History of the social and political landscape surrounding medical decision-making and contraceptives provide an understanding of why the topic of SDM, especially for contraceptive counseling, is of substantial interest. Key Historical Developments in Contraception Despite increasing access to contraceptive options and widespread uptake of modern contraceptive methods, the historical implementation of contraception healthcare in Canada and globally has been shaped by complex and, at times, troubling dynamics (Bain, 1964; Dicenzo et al., 2025; Grekul et al., 2004). For much of the 20th century, contraception was legally restricted, and it was not until 1969 that contraception use in Canada was decriminalized through amendments to the Criminal Code (Black, 2019). However, following this legal change, access 3 has remained unequal and influenced by social inequities (Brandi & Fuentes, 2020; DiCenzo et al., 2025; Donnelly, 2024; Standing Senate Committee on Human Rights, 2022). Notably, modern contraception practices in Canada have a documented history of being tied to coercive and discriminatory practices (Bain, 1964; Grekul et al., 2004). During the 20th century, eugenics-driven policies disproportionately targeted Indigenous women, immigrants, and those deemed "unfit" to procreate through provincially-run sterilization programs (Grekul et al., 2004). While some public health initiatives framed contraception to improve maternal health and reduce negative outcomes from unintended pregnancies, these aims were often implemented in paternalistic ways that prevented capable individuals from exercising meaningful choice (Bain, 1964; Grekul et al., 2004). These historical injustices have ongoing consequences. Recent reports emphasize that some Indigenous women in Canada continue to experience coercion in reproductive healthcare, including being pressured into accepting long-acting reversible contraception or involuntary sterilization (McKenzie et al., 2022; Senate Committee on Human Rights, 2022). The fact that such experiences continue to occur underscores the need to further focus on ensuring patient autonomy and allow for meaningful choice in reproductive health and contraceptive options. These experiences also reinforce the need for healthcare providers to ensure a culturally safe and patient-centered approach to care provision. Because these issues continue to exist, reproductive justice has emerged as a critical framework that centers the right of all individuals to their own bodily autonomy, to have or not to have children, and to parent in a safe environment. First established by Black women in the United States, the reproductive justice movement broadens the reproductive focus beyond individual access to contraception or abortion and instead emphasizes the systemic barriers to choice faced by marginalized groups (SisterSong, n.d.). This framework also aligns with a shift 4 urged by the 1994 International Conference on Population and Development (ICPD), which advocated for a move away from population control rhetoric toward people-centered, rightsbased care (United Nations Population Fund, n.d.). However, critics argue that mainstream family planning metrics, such as contraceptive uptake or fertility reduction, still reflect a population-level, goal-oriented framework rather than a rights-based one (Senderowicz, 2020). In contrast, the concept of contraceptive autonomy emphasizes whether individuals are using a method they genuinely desire, selected through an informed choice and free from the effects of pressure or coercion (Senderowicz, 2020). Achieving such an ideal requires clinical encounters that are not only informative but also deeply collaborative, making SDM an important component of modern contraceptive counselling. Clinical encounters that pertain to contraception should be viewed as key moments to support patient autonomy, address power imbalances that could inappropriately influence a patient decision, and foster trust. In the context of the complex history and the ongoing inequities surrounding contraception use, SDM has emerged as a promising model. SDM may be helpful in supporting contraceptive counselling that aligns with the principles of reproductive justice and people-centered care by emphasizing patient preferences, goals, and priorities in the decisionmaking process (Dehlendorf et al., 2017; Silva et al., 2022). Shared Decision-Making The concept of SDM grew in popularity in the 1980s as a response to the increasingly recognized limitations of paternalistic care models being used at that time in clinical situations (Charles et al., 1997; Makoul & Clayman, 2006). SDM is particularly relevant in clinical scenarios that are preference-sensitive, such as situations in which multiple medically appropriate options exist and the “best” choice depends upon the individual’s goals, values, and context (Charles et al., 1997; Dehlendorf et al., 2017). Contraceptive counselling is one such 5 example; it involves navigating a range of acceptable options that differ in side effect profiles, effectiveness, ease of use, and alignment with personal or cultural beliefs (Black, 2019; Brandi & Fuentes, 2020; Dehlendorf et al., 2017; Dicenzo et al., 2025). Unlike informed decision-making, which often relies on a one-directional transfer of information from provider to patient, SDM emphasizes a collaborative process in which clinicians and patients both contribute; the clinician offers evidence-based guidance while the patient shares their preferences, priorities, and lived experience (Charles et al., 1997; Makoul & Clayman, 2006; Shay & Lafata, 2015). This model is particularly well-suited to reproductive health contexts, because power imbalances and historical violations of bodily autonomy may affect patient trust and willingness to engage in care. Although a universal definition and consistent measurement of SDM remains difficult to establish, systematic reviews have demonstrated that greater patient-reported SDM is associated with improved cognitive outcomes, patient satisfaction, and engagement in care (Shay & Lafata, 2015). Specifically in the context of contraceptive counselling, studies suggest that patients who experience SDM report greater satisfaction with their contraceptive choices and decision-making processes (Dehlendorf et al., 2017). However, despite growing support for SDM in contraceptive care, there is limited synthesis regarding how it has been applied in the specific context of contraceptive counselling. A prior integrative review by Silva et al. (2022) explored SDM interventions and tools used in contraceptive counselling, but the review only included studies published up to and including 2019. While the findings were promising, highlighting increased satisfaction and more personcentered care, ongoing research is still needed to capture newer models and evolving understandings of what SDM can and should look like in this context. 6 Aim of Integrative Review Primary care providers, including family physicians and nurse practitioners (NPs), are well-positioned to implement SDM in contraceptive counselling, particularly when individuals are seeking prescription-based contraceptive options. The aim of this integrative review is to synthesize recent literature examining tools or strategies explicitly designed to promote SDM in the context of contraceptive counselling. Recognizing that providers’ perceptions of SDM may not always align with patient experiences of it, this review will prioritize studies that evaluate patient-reported outcomes through either qualitative or quantitative methods (Shay & Lafata, 2015). By focusing on the patient perspective, and in keeping with previous work to establish a conceptual understanding of the SDM process for treatment options, the goal is to assess the effectiveness and outcomes of SDM-promoting interventions in achieving truly collaborative, informed, goal- and value-congruent decisions (Charles et al., 1997; Makoul & Clayman, 2006). This analysis will serve to provide a greater understanding of what tools or strategies can be used by providers in the primary care setting to promote SDM during contraceptive counselling. 7 Chapter Two: Methods The purpose of this integrative review is to address the question: how can providers use tools or strategies to support SDM for contraceptive counselling in primary care? To answer this question, the integrative review framework by Toronto (2020) was used, allowing for inclusion of both qualitative and quantitative research, as well as mixed-methods studies. This chapter outlines the systematic steps taken to identify and select relevant literature, including database selection, search strategy, and inclusion criteria. It also describes the exclusion criteria that were used to narrow results down to the final seven articles included in the integrative review. The process for critical analysis and data extraction for the selected articles is also briefly described. The method used in this review was based on the integrative review framework outlined by Toronto (2020): formulate the review question, systematically search and select literature, appraise quality of literature, analyze and synthesize findings, discuss and disseminate findings. This framework was chosen to allow for the broadest range of approaches and methodology in the included literature, such as qualitative, quantitative, and mixed-methods studies, while maintaining a rigorous and systematic process (Toronto, 2020). Including quantitative, qualitative, and mixed-methods studies allowed for a deeper exploration of the use of SDM in practice by examining patient experiences as well as quantitative outcomes. Database Selection A systematic literature search to identify research articles that were relevant to the research question was conducted using MEDLINE Ovid and CINAHL. MEDLINE Ovid was selected for two reasons. Firstly, the scope of MEDLINE includes articles within the scope of biomedicine and health in over 5200 journals (National Library of Medicine, 2024). Accessing MEDLINE via the Ovid platform allowed for enhanced search capabilities due to its precise organization using subject headings, and advanced search operators (Wolters Kluwer, n.d.). 8 CINAHL was chosen for its wide scope of nursing and allied health literature, necessary since NPs are also primary care providers who provide contraceptive counselling (EBSCO, n.d.). Search Strategy The search strategies used included combinations of relevant search terms to build the concepts of SDM in relation to contraceptive options. When the concepts of primary care and primary care providers were included in the search terms, the number of relevant articles returned was very small, ranging from 5 to 20 articles; as a result, these two terms were removed when conducting the next set of searches and instead were re-instituted as inclusion criteria during the abstract review stage of the integrative review process. The full list of search terms and subject headings, and their combinations, that were used in both databases are shown in Appendix 1. A previous integrative review on the use of SDM in contraceptive counselling had included articles published up until the year 2019 (Silva et al., 2022). As a result, this current integrative review used a date range of 2019 to 2024 to bridge the timeframe between the earlier integrative review and the year in which this current review was undertaken. In addition to this date restriction, non-English articles were excluded from the review; the author’s first language is English and reliable and precise research translation services were not available. An initial search conducted without the date restriction included had yielded a total of 737 articles; these results were narrowed to 352 articles after excluding duplicates, applying the inclusion criterion of date range from 2019 to 2024, and removing non-English articles. Abstracts of these 352 articles were scanned by the author for relevance to the research question, using the following criteria for inclusion: (1) the study evaluated a tool or strategy to promote SDM for contraceptive counselling; (2) the tool or strategy could be implemented in a primary care setting, e.g. was implemented in a clinic-based setting and not in an inpatient or 9 acute care setting; (3) researchers had evaluated patient perceptions and experiences with the tool or strategy; and (4) the study participants were females of reproductive age, generally defined to be from 15 to 49 years old (Carpino, 2025; World Health Organization [WHO], n.d.). The first two criteria were chosen to ensure the selected texts aligned with the core concepts of the research question, i.e. SDM tools or strategies used in a primary care setting. The third criterion, that researchers had explored the patient perspective in the study, was included because an essential component of the movement towards SDM for contraceptive counselling involves a shift away from the paternalistic provider-centric approach to providing care (Charles et al., 1997; Dehlendorf et al., 2017; Makoul & Clayman, 2006). Thus, the patient perspective is an essential aspect of investigating how tools or strategies can be effectively used to promote SDM in practice. Studies which targeted the population of females of reproductive age were included given that most current contraceptive options have been developed for use by individuals with a uterus (WHO, n.d.). While not all individuals with a uterus identify as women, and not all those who identify as women have a uterus, the term “women” is generally used throughout contraception-related literature to refer to those with a uterus. For consistency with the reviewed literature, the term “women” will be used throughout this integrative review to refer to individuals with a uterus. However, this definition is not necessarily suited to all individuals, and it is important that providers consider gender identity and expression on an individual basis during patient interactions (British Columbia Ministry of Health, 2025). Scanning abstracts for relevance to the research question based on the above criteria led to a total of 29 articles selected for full text review. Seventeen articles were excluded from the review because they did not assess a tool or strategy for SDM in practice. One study was retained for the integrative review despite the patient/provider discussion not occurring in a contraceptive counselling session because that discussion had taken place in a simulated contraceptive 10 counselling appointment. The simulated nature of this intervention compared to actual, real life provider interaction was considered when interpreting the study results. Two studies were excluded after full text screening as they did not evaluate the patient’s impressions or experiences with the SDM strategy or tool, and only elicited feedback from the provider. Three studies were removed from consideration because they did not include the target population of females of reproductive age. Reviewing the reference lists of the seven articles ultimately selected for the integrative review did not lead to the inclusion of any additional articles. A completed PRISMA flowchart outlining the above steps is provided in Appendix 2. Critical Appraisal and Data Extraction Seven studies met all of the criteria and were retained for this integrative review. Four of these studies were quantitative studies, one was a qualitative study, and one employed a mixedmethods research methodology. Critical appraisal and data extraction were completed for each of these seven studies over multiple iterative rounds; a table that shows the results of the appraisal and extraction process is included as Appendix 3. Critical appraisal elements suitable for the range of methodology of the included studies were chosen based on Critical Appraisal Skills Programme (CASP) checklists and incorporated into the data extraction matrices (Critical Appraisal Skills Programme, n.d.). These elements included study design and methodology, outcome measurements, strengths and limitations of each study, and feasibility. Broader elements such as sample characteristics, type of tool or strategy used, and key findings were also used to fulfill data extraction requirements. 11 Chapter Three: Findings The seven studies included in this integrative all evaluated the use of a tool or strategy to support SDM for contraceptive counselling in a non-acute practice setting. Table 1 summarizes the key characteristics of each of these studies, including the geographic location in which it was conducted, the type and name of each tool or strategy used, the number of patients included in each study, and whether a control/comparison group was used for those studies that used a quantitative methodology. Table 1. Key study characteristics Study Country Type of tool or strategy Bitzer et al., 2021 Germany Structured needs-based questionnaire Callegari et al., 2021 United States Dehlendorf et al., 2019 Study type Patients (n) Control group Quantitative 1176 N/A Interactive web-based decision support tool (My Path) Quantitative 58 Yes United States Interactive iPad-based decision support tool (My Birth Control) Quantitative 749 Yes Korger et al., 2021 Germany Narrative or non-narrative decision aid support text Quantitative 238 Yes Lee et al., 2021 United States Physical model of contraceptive options (The Tool) Mixed methods 40 No Wackenhut et al., 2021 United States Educational videos, charting prompts, and staff training Quantitative 53 No White et al., 2021 United States Structured interview guide for providers Qualitative 12 N/A Note. Data extracted from the seven studies included in integrative review. See reference list for full details. 12 Study Setting and Participants Nearly all the studies were conducted in the United States (Callegari et al., 2021; Dehlendorf et al., 2019; Lee et al., 2021; Wackenhut et al., 2021; White et al., 2021) aside from two which were conducted in Germany (Bitzer et al., 2021; Korger et al., 2021). Several studies were implemented in providers’ offices as part of their usual contraceptive counselling appointments (Bitzer et al., 2021; Callegari et al., 2021; Dehlendorf et al., 2019; Lee et al., 2021; Wackenhut et al., 2021). In contrast, the study participants in White et al. (2024) received contraceptive counselling over Zoom from a provider who was not part of their regular health care team. Another study, Korger et al. (2021), did not include actual clinical providers in their study but instead showed participants a video of a provider discussing a contraceptive option for them to consider. Two of the studies were conducted in primary care clinics (Callegari et al., 2021; Wackenhut et al., 2022). Dehlendorf et al. (2019) conducted research across four different types of clinics: family planning clinics, a college health center, outpatient clinics, and public health clinics. Lee et al. (2021) conducted their research study at a university health clinic. Most of the providers across studies were physicians; however, several studies also included NPs and other health care professionals (Dehlendorf et al., 2019; Lee et al., 2021). In one study, all participant interviews were conducted by the same gynecologist, which helped to ensure consistency across counselling methods (White et al., 2024). In the study by Korger et al. (2021), providers were not included as the study did not involve an actual contraceptive counselling session but instead patients were asked to watch a pre-recorded video and then place themselves in the position of the patient; the video was intended to simulate the way in which a provider would present information during an appointment. Some studies used only specialist obstetrical and gynecological (OB/GYN) specialist physicians to provide the contraceptive counseling to patient participants (Bitzer et al., 2021), while others used a combination of 13 specialist OB/GYN physicians, NPs, and physician assistants (PAs) (Lee et al., 2021). Two studies did not specify if the providers used in their study were specialists, but they did indicate that the consultation sessions had occurred in a primary care setting and had involved both physicians and NPs (Callegari et al., 2021; Wackenhut et al., 2021). All studies included women of reproductive age, and therefore the age ranges of patient participants were similar across studies (see Appendix 3). Although Lee et al. (2021) stated their intention to focus on youth and adolescent populations, the age range of included participants for this study was 15 to 29 years of age. The study conducted by Bitzer et al. (2019) similarly included patients aged 16 to 30 years of age. The study by White et al. (2024) included a smaller age range of patients from 23 to 28 years old, while all remaining studies included both adolescent and adult participants (Bitzer et al. 2021; Callegari et al., 2021; Dehlendorf et al., 2019; Korger et al., 2021; Lee et al., 2021; Wackenhut et al., 2021). The self-reported ethnicities of patient participants in several of the U.S. studies, those by Dehlendorf et al. (2019) and Lee et al. (2021), were diverse, often including patients who selfidentified White (23% and 17.5% respectively), Latina/Hispanic (38% and 12.5% respectively), Asian (16% and 24% respectively) or African American/Black (10% and 32.5% respectively). However, in the study conducted by Callegari et al. (2021), all participating patients were women veterans and most of the participants (53%) self-reported their ethnicity as White. Both studies that were conducted in Germany did not include any information about the ethnicity of their patient participants (Bitzer et al., 2019; Korger et al., 2021). Tools or Strategy Used Two studies used web-based decision support tools (DSTs) to be completed by patients ahead of their regular contraceptive counselling appointment with the provider (Callegari et al., 2021; Dehlendorf et al., 2019). In one study, patients completed a survey as part of the tool 14 called MyPath on an iPad directly before the appointment (Callegari et al., 2021). Development of MyPath was informed both by self-determination theory and by existing literature. The intent was to support autonomy and self-efficacy for women in considering their reproductive goals (Callegari et al., 2021). Completion of the MyPath questionnaire ends in a summary page which lists the patient’s thoughts on their desire for pregnancy, their level of concern regarding the chance of becoming pregnant, current contraceptive method and satisfaction with that method, other hormonal information, and contraceptive methods that they might want to discuss with their provider. The authors reported that they had developed this intervention based on evidencebased decision aid protocols, literature reviews, consultation with experts, and primary care provider focus groups with women veterans; they also indicated that the contraceptive portion of the MyPath DST had been based on another DST for contraceptive choices, My Birth Control (Callegari et al., 2021). The My Birth Control tool was the primary focus of research by Dehlendorf et al. (2019). In that study, participants completed the interactive survey on an iPad immediately before their appointment with the provider. My Birth Control provides information on contraceptive options and then asks the patient answer survey questions designed to elicit needs and preferences; this results in tailored recommendations for contraceptive choices (Dehlendorf et al., 2019). Patients are then able to bring the list into the appointment to discuss with their provider. Development of the tool was based on previous research on women’s needs in contraceptive counselling, stakeholder consultation, and pilot testing (Dehlendorf et al., 2019). Wackenhut et al. (2021) also incorporated web-based content for patients to use ahead of appointments as part of the overall strategy to support SDM. This was the only study in the integrative review that implemented a range of interventions to broadly affect the providers’ practice in the clinic. In this sense, the study targeted the clinic at large, rather than individual 15 appointments, and was also a quality improvement project (Wackenhut et al., 2021). The study involved staff training about SDM, but it also provided educational material for patients to view prior to contraceptive counselling appointments, and inserted prompts in electronic medical records to guide providers in implementing SDM practices (Wackenhut et al., 2021). This strategy had been informed by engagement with clinic staff and providers in which they had assessed patient needs and chosen which strategies to implement. Studies by Bitzer et al. (2021) and White et al. (2024) evaluated the use of questionnaires during contraceptive counselling appointments as a way to support SDM. In Bitzer et al. (2021), known as the “COCO study”, authors developed the questionnaire based on previous research and on counselling experiences of the authors. In the COCO study, providers asked multiple- choice questions to elicit preferences and needs of patients, regarding reliability, effects of hormones, and more. Patients’ responses were then used by the providers to narrow the list of suitable contraceptive options (Bitzer et al., 2021). In their study, White et al. (2024) also required the provider to implement a semi-structured questionnaire to elicit patient needs and preferences. The PHI CARE Model was the tool used in White et al.’s study and is an acronym for the steps of the entire counselling session: Past, Health history, Important, Counselling, Autonomy, Reviews, and Experience (White et al., 2024). The PHI CARE model involves a series of open-ended questions, such as asking about the patient’s contraceptive journey to that point in time and asking the patient to articulate those factors that are important to their contraceptive choices, rather than providing predetermined criteria for questions (White et al., 2024). Lee et al.’s (2021) research also used the term decision aid to describe the tool implemented for the purpose of supporting SDM in their research. They referred to this as The Tool, and it consisted of physical models of contraceptive options attached to a ring. Authors in 16 this study described a lengthy process for the conceptualization, design, and finalization of The Tool (Lee et al., 2021). The Tool had been developed out of engagement with youth in the same area as where the research was conducted, and it had been developed by industrial designers with feedback from both health care providers and youth (Lee et al., 2021). Providers were given The Tool without instructions on how to use it during contraceptive counselling appointments, aside from directing them to ensure that the patient would be given an opportunity to handle the physical models during the appointment (Lee et al., 2021). Lastly, Korger et al. (2021) developed a narrative decision aid designed not to alter the content of contraceptive counselling itself, but to support participants in considering their own values and preferences in considering contraceptive options. The aid presented patient testimonials or written scenarios involving individuals considering a switch from oral contraceptives to an intrauterine device (IUD). These narratives aimed to help patients reflect on factors such as cost, side effects, and personal preferences, thereby guiding them in clarifying their values and making more informed contraceptive decisions. Study Design and Methodology Five studies included in this review were quantitative (Bitzer et al., 2021; Callegari et al., 2021; Dehlendorf et al., 2019; Korger et al., 2021; Wackenhut et al., 2021) while the remaining two studies were either qualitative (White et al., 2024) or mixed methods (Lee et al., 2021). Beyond the differences in their overall study design, there were also differences between the seven studies in participant recruitment strategies, outcome measurements, and data analysis. In several studies, recruitment was conducted by speaking with patients who arrived for clinic appointments booked for contraceptive counselling (Dehlendorf et al., 2019; Lee et al., 2019; Wackenhurt et al., 2021), or reaching out by letter ahead of appointments (Callegari et al., 2021). Korger et al. (2021) recruited students via email, who were incentivized to participate 17 with a chance to win a prize. In this study, an eligibility criterion was that participants must already be taking OCs before engaging in the study, as this was pertinent to the simulated patient scenario in the study (Korger et al., 2021). Several other studies also offered a financial incentive to patients for their participation (Lee et al., 2021; White et al., 2024). For the PHI CARE study, participants were recruited through a gynecology clinic using convenience sampling (White et al., 2024). As shown in Table 1, several studies used a control or comparison group to evaluate the effectiveness of the intervention in supporting SDM. Two of the included studies were randomized control trials (Dehlendorf et al., 2021; Korger et al., 2021). One study utilized four different clinics, and the unit of randomization for that study was the clinical site (Dehlendorf et al., 2021). Due to the controlled nature of the simulated clinical encounter and interventions provided in Korger et al.’s (2021) study, it was likely most effective among studies at controlling for variables between intervention and control groups. Wackenhut et al. (2021) used a baseline assessment to provide a point of comparison for surveys administered to contraceptive postimplementation of the SDM supporting strategy at the clinic. The MyPath study also used a preimplementation non-controlled baseline group for their “usual care” group before implementing the intervention in the study clinic (Callegari et al., 2021). Studies that did not include control or comparison were an observational study (Bitzer et al., 2019), a mixed-methods study (Lee et al., 2021) and a qualitative study (White et al., 2024). Outcomes and Applicability Most patient participants provided positive feedback on the interventions used (Bitzer et al., 2021; Callegari et al., 2021; Lee et al., 2021; Wackenhut et al., 2021; White et al., 2021). However, the types of outcomes measured, and how they were measured, varied across studies. Some of the SDM tools or strategies are likely to be easily applicable in most primary care 18 settings, while others could be more challenging to implement in situations of resource scarcity or time constraints. Several studies used Decisional Conflict Scales as outcome measurements (Callegari et al., 2021; Dehlendorf et al., 2019; Korger et al., 2021). Callegari et al. (2021) examined levels of decisional conflict regarding their choice of contraceptive method before and after appointments; they found that, although the pre-test to post-test decrease in decisional conflict scores were greater in the intervention group (23.3%) compared to control (7.1%), the difference was not statistically significant (p=0.09). Dehlendorf et al. (2021) did not note an overall difference on the decisional conflict scores between intervention and control groups. Korger et al. (2021) did find significantly higher levels of decisional certainty in both the narrative decision aid and written decision-strategy groups compared to control (p<0.001), and they also found that these groups felt significantly more prepared for decision-making compared to control (p<0.001) . However, it is worth noting that the participants in this study had not actually been asked to make an actual decision regarding their own contraception methods and were instead considering a hypothetical change in method (Korger et al., 2021). Dehlendorf et al. (2019) also investigated patient perceptions of the SDM tool used for contraceptive counselling and they conducted brief follow-up surveys with patients several months after the initial appointment. To assess patient’s experience of contraceptive counselling, researchers used the Interpersonal Quality of Family Planning Scale (IQFP). The intervention group was significantly more likely to report the greatest level of interpersonal quality of counselling compared to the control group (66.0% vs 57.4%). At 7-month follow up, researchers found that 56.6% of the intervention group had continued their chosen contraceptive method, compared to 59.6% in the control group. Researchers also aimed to assess SDM by measuring the patient’s perception of whether the patient, provider, or both had final decision regarding the 19 type of contraception chosen. They found no significant differences for these measures, and in both control and intervention groups, 72% of patients reported that they had made the decision. Callegari et al. (2021) also used other validated scales for outcome measurements, such as the modified IQFP scale and Perceived Efficacy in Provider-Patient Interactions, which they measured prior to and after using the MyPath tool. There were no significant differences between the increases in IQFP scale between intervention and control, and both groups rated this highly (mean scores of 4.7 and 4.8 out of 5, respectively). Perceived self-efficacy scores, however, did increase by 0.8 after use of the My Birth Control tool in in the intervention group, which was found to be significantly higher when compared to the control group, in which scores only increased by 0.2 (p=0.02). Not all studies included in this review had made use of validated measurement scales for measuring outcomes. Bitzer et al. (2021) did not use validated tools for their outcome measures, but they did collect quantitative data on participant perceptions of the structured contraceptive counselling. Researchers instead measured participants’ agreement with statements regarding the quality, clarity, helpfulness and suitability of the counselling. They found that 68% of women rated the counselling as “very good”, and that 80% of women found it was easy to understand. Researchers in this study also were able to collect data on the number and types of contraceptive methods discussed during the appointments. They found that the more contraceptive methods were discussed in a session, the higher the participant rated their satisfaction. Both providers and patients had positive ratings of the counselling sessions, however patients in this study were more likely to rate the quality of counselling as “very good” compared to providers (68% vs 12%). Lee et al. (2021) collected more limited quantitative data on study outcomes compared to the studies described above. They reported that 95% of patients considered the physical model of 20 contraceptives to be helpful for making contraceptive decisions, and 92% of patients reported appreciating the visual aspect of The Tool. According to qualitative data collected from providers in the study, The Tool also helped dispel myths around types of contraceptives, such as the size of an IUD, and it helped patients to organize their thoughts during appointments while also making the conversations more patient-centered (Lee et al., 2021). Wackenhut et al. (2021) also provided limited quantitative data compared to other studies. However, they did mention that, following the implementation of the SDM strategies in the clinic, patients were significantly more likely (p=0.031) to report that sufficient information had been provided during their contraceptive counselling appointments (Wackenhut et al., 2021). Qualitative data collected for the PHI CARE protocol revealed several themes about participant perceptions of contraceptive counselling (White et al., 2024). One such theme was that the counselling represented a more collaborative approach to a process that had previously involved unilateral information provision from the provider. Another theme was a perceived shift in the locus of control from the provider to the patient, which led to patients experiencing feelings of empowerment. Data also revealed that, despite the standardized approach used in this study, participants had perceived the counselling they received as being individualized and tailored to their own unique needs and values. Participants were particularly appreciative of being asked what was important to them regarding their birth control method. The interventions described in the selected articles would likely be quite feasible to implement in primary care in terms of cost or the equipment needed, and many studies which assessed for overall satisfaction, likeability, or acceptability of the interventions reported positive results. Lee et al. (2021) found that 100% of participants would recommend use of The Tool for others their age discussing contraception with providers. In Bitzer et al.’s (2019) study, 95% of patients rated the quality of contraceptive counselling provided as “very good” or “good”. 21 Among patients using the MyPath tool, 83% of participants liked the tool and found it to be helpful (Callegari et al., 2021). However, time constraints and generalizability could prove challenging with certain tools, particular those used during appointment. For example, the structured PHI CARE tool took an average of 22 minutes to complete and could result in decreased feasibility (White et al., 2024). Although some providers found that the physical model of contraceptives used (The Tool) accelerated conversations with patients about contraceptive options, others found it was quite time-consuming if patients wished to consider and discuss each option on the ring (Lee et al., 2021). It was proposed that tools that could be used before office appointments would likely make counselling more efficient and not require extra time during appointments (Callegari et al., 2021; Dehlendorf et al., 2021). However, not all of the studies measured or reported the amount of time required for the tools or strategies to be implemented. 22 Chapter Four: Discussion The above findings demonstrate that a range of tools or strategies can be used effectively to support SDM in the contraceptive counselling process. An even wider range of patient or participant outcome measurements can be used following the implementation of these interventions. To understand how these tools or strategies can support SDM in contraceptive counselling, the actual process of SDM used in the studies and the outcomes measured in this context are considered below. Implications for future research and practice are also discussed. Several studies in this integrative review used decision aids as tools to support for contraceptive counselling (Callegari et al., 2021; Dehlendorf et al., 2019; Korger et al., 2021; Lee et al., 2021). Decision aids help patients to understand their treatment options and how their values might influence their choice of treatment (International Patient Decision Aid Standards Collaboration, 2005). Early scholars of SDM contended that, in the process of choosing among multiple treatment options, decision aids can provide manageable steps for presenting information, which can also help clarify patient values and priorities; this also can help to support more active patient engagement in the decision-making process (Charles et al., 1997). Additionally, a systematic review on decision aids found that they can improve patient knowledge, enhance accuracy in risk perception, and increase alignment between individual values and selected care options (Stacey et al., 2017). In Makoul and Clayman’s (2006) efforts to provide a list of essential elements of SDM, they recommended several steps that need to occur within conversations between providers and patients, including: presenting and discussing treatment options, exploring patient values and preferences, sharing provider recommendations, assessing patient ability and understanding, and finally arriving at consensus on a decision. Considering the evidence surrounding the use of decision aids in practice, it makes sense that authors would implement these steps to support 23 SDM for contraceptive counselling. Essential elements of SDM, such as presenting available options along with relevant pros and cons of each, and clarifying patient values and priorities, may all be facilitated through use of decision aids that help elicit patient values and present options in a structured or more transparent fashion. Decision aids in the form of web-based DSTs were implemented as SDM tools and were included in the studies of this review, including My Birth Control (Dehlendorf et al., 2019) and MyPath (Callegari et al., 2021). As described in the Findings chapter, patient ratings of interpersonal quality of counselling or decisional certainty were higher when DSTs were used during appointments. However, only one study examined whether patient perceptions of whether the decision was shared or provider-driven, and it found no group differences in these perceptions between intervention and control. Thus, we can conclude that the tools used can support aspects of SDM, such as presenting options and exploring patient preferences. However, the studies did not necessarily capture the actual content of the conversations between provider and patient, and therefore it cannot be clearly established that the essential step of mutual information-sharing between provider and patient has occurred (Makoul & Clayman, 2006). Furthermore, the patient-reported outcomes in these studies do not directly provide evidence that the decision-making process was collaborative or was shared between patient and provider. In the experimental study by Korger et al. (2021), decision aids in the form of patient testimonials or written decision strategies were used to support patients in exploring their own personal motives and preferences for changing contraceptive options. This study was the only one among those reviewed that did not involve an actual provider-patient interaction; researchers instead had patients consider a hypothetical scenario and a simulated provider interaction. The controlled environment provided consistency across participant experiences, which could have increased internal validity of the results. However, although significant increases in decisional 24 certainty and preparedness were found in this study, it is not clear whether these findings can be reproduced in an actual appointment for contraceptive counselling. Similar to the two DSTs used prior to appointments, this type of tool may be effective for assisting patients in exploring their values and considering options, but does not necessarily include a full collaborative dynamic of SDM between patient and provider. Unlike other studies in this review which implemented use of decision aids prior to appointments, in Lee et al.’s (2021) study the participants had access to a physical model of contraceptive options, The Tool, during contraceptive counselling with providers. This was the only study that used a decision aid during interactions, and authors noted that minimal direction had been given for providers on how to use The Tool (aside from ensuring that participants could hold the tools themselves and ask questions throughout the discussion). The content of the counselling was also not recorded or analyzed as part of this study, nor was a control group used for comparison; however, the quantitative data reported did indicate that the tool was helpful in decision-making (Lee et al., 2021). Qualitative data collected from providers indicated that the tool might help patients organize their thoughts regarding the different methods of contraception. Although this study did not measure the process of SDM through observation or recording of conversations between provider and patient, it did suggest that this type of tool may be useful for assisting in the collaborative discussions between patients and providers. Providers can more easily share information with the patient through reference to the physical tool, and patients can better organize their thoughts by referring to the model throughout the conversation (Lee et al., 2021). Two studies that did not make use of any form of decision aid for SDM instead implemented either a structured questionnaire (Bitzer et al., 2021) or a counselling protocol (White et al., 2024) as their strategy to promote SDM in contraceptive counselling. Bitzer et al.’s 25 (2021) study used the structured questionnaire during appointments and found that participants were significantly more satisfied with this type of counselling compared to usual appointments. They also found that participants rated the counselling appointment more highly that providers did (Bitzer et al., 2021). Themes such as empowerment and an individualized approach were revealed in White et al.’s (2024) qualitative data after using the open-ended PHI CARE protocol. It was difficult to compare these findings to those of the studies that used decision aids, as all used different outcome measurements. However, in theory, the use of strategies to direct the content of the discussion during appointments was viewed as directly promoting collaborative conversations between providers and patients, which would be a better reflection of the SDM process (Charles et al., 1997; Makoul & Clayman, 2006). However, use of structured questionnaires or protocols during appointments is also less efficient than tools that can be used independently by patients ahead of time. The process of contraceptive counselling took an average of 22 minutes in the PHI CARE protocol, which researchers noted may be overly time- consuming and therefore lack feasibility for clinic settings (White et al., 2024). As discussed above, several studies that implemented tools to support patient-centered case and SDM in contraceptive counselling did not analyze the process of SDM in the context of the patient-provider interaction. This was similar to a concern raised by past researchers, that there was a prominent lack of studies investigating the association between an empirically measured model of SDM and patient outcomes (Shay & Lafata, 2015). This past research also identified that there has been substantial variability in outcome measurements used for assessing the outcomes of SDM for choosing treatment, an observation that also aligns with the findings of this integrative review (Shay & Lafata, 2015). In terms of the outcomes of using SDM in contraceptive counselling, it is also worth reflecting on whether outcome measures used in studies truly reflect promotion of contraceptive 26 autonomy (Senderowicz, 2020). Due to historical injustice in the implementation of contraceptive methods in healthcare, contraceptive autonomy has been cited as a motivating factor for using SDM with patients who are making contraceptive choices (Senderowicz, 2020). Organizations have increasingly shifted towards prioritization of highly effective birth control methods, such as long-acting reversible contraceptives (LARC), as these methods offer the most effective protection against unintended pregnancies (Black, 2019). In this integrative review, the RCT study by Dehlendorf et al. (2019) included choice of a LARC as an outcome of interest. Bitzer et al. (2021) also included a LARC option as one outcome measurement for their study and found increased uptake of LARC to be associated with SDM. Although the use of highly effective birth control methods offers benefits and may certainly be most suitable for many individuals, it is questionable whether this would be the desired outcome of implementing SDM in contraceptive counselling. If a patient is meant to participate in the conversation regarding their contraceptive choice, and to find a choice that best reflects their goals and preferences, then it cannot be appropriate that any particular method of contraception should be the “desired” outcome. Furthermore, in recent years, there is evidence that some providers may be pressuring patients into selecting highly effective methods of contraception, or into maintaining the use of such methods, despite patient requests to the contrary (Amico et al., 2017; Fox et al., 2024). These pressures from providers often reflect a paternalistic approach to determining a patient’s contraceptive needs (Amico et al., 2017). Thus, implementing tools or strategies in contraceptive counselling with the specific intention of increasing the use of more effective methods of contraception for all patients may actually compromise, rather than enhance, SDM. 27 Implications for Future Research To more explicitly link SDM to measured outcomes in studies, future investigations should specifically examine the dynamics of conversations that occur between providers and patients and link them to patient perceptions and outcomes following appointments. Although this may be challenging due to confidentiality in patient appointments, even small-scale studies or studies that simulate appointments may be helpful to more accurately capture and assess this aspect of the process. When studies evaluate SDM based on the implementation of a tool or strategy that is meant to support the SDM process, but do not explicitly ensure that the process is aligned with an accurate understanding of SDM in practice, it will be challenging to establish any causal or correlative link with outcomes. For future studies that use decision aids prior to appointments, it is possible that authors may need to accept that aspects of the SDM process, such as the presentation of choices and sharing of information, may be substituted by using webbased DSTs (Callegari et al., 2021; Dehlendorf et al., 2019). However, researchers might also implement methods to ensure that providers revisit patient understanding and interpretation of the information presented in those DSTs. Valuable research might also include comparisons of decision aids used before appointments with strategies that implement the SDM process during the appointment, such as structured questionnaires or protocols (Bitzer et al., 2021; White et al., 2024). Researchers could also use outcomes that were part of several studies included in this review, such as decisional conflict, decisional preparedness, interpersonal quality of family planning, and perceived selfefficacy in provider-patient interactions. Studies that compare tools or strategies that previously appeared in the literature, along with commonly used outcome measurements, would strengthen our understanding of the link between those interventions and outcomes. 28 Future work might also consider increasing research regarding SDM in contraceptive counselling in the Canadian primary care setting. Although tools exist for contraceptive counselling, such as the Society of Obstetricians and Gynaecologists of Canada’s (SOGC, n.d.) online DST for contraceptive methods, It’s a Plan, there were no studies which evaluated this tool in practice. Although the tools or strategies described in the studies that were part of this review could reasonably be implemented in almost any primary care setting, none of these studies were based in Canada or reflected the social or geographical considerations which may impact many rural Canadian communities. Furthermore, given colonial history and the continued effects of past forced or coerced sterilization, which affected many Indigenous individuals along with other marginalized groups, ensuring SDM in this context is of vital importance (Standing Senate Committee on Human Rights, 2022). Implications for Practice The findings of this integrative review suggest that the use of decision aids prior to appointments is generally considered helpful and acceptable to patients and can decrease time spent deliberating on which treatment options are best suited to a patient’s values, goals and preferences. If feasible, providers could have a system in place wherein these tools are sent to patients before upcoming appointments, for completion in the home setting (Callegari et al., 2021). However, use of decision aids before appointments should still be supplemented with further conversations between the provider and patient, as those additional discussions continue to include aspects of SDM such as mutual sharing of information, exploration of patient values and preferences, and confirmation of patient understanding. Structured approaches used during appointments may help ensure a more consistent SDM process, such as the PHI CARE model described by White et al. (2024). Although this approach does require an increased investment of provider and patient time, the open-ended nature of the 29 questions was highly appreciated by patients (White et al., 2024). Open-ended questions allowed providers and patients to explore nuances in patient goals and priorities that could influence their choice of contraceptive (White et al., 2024). Although using DSTs or DAs before the appointment is efficient and improved patient knowledge, a structured approach to counselling with open-ended questions was found to better reflect the collaborative nature and bidirectional sharing of information that defines the SDM process (Charles et al., 1997; Makoul & Clayman, 2006; Shay & Lafata, 2015). Ensuring use of even one open-ended question, such as “What is important to you about your birth control?”, was found to be highly appreciated by patients and would be a valuable starting point for providers hoping to implement the SDM approach into contraceptive counselling (White et al., 2024). Beyond decision aids and structured interview approaches, the physical model of contraceptives that is part of The Tool provided a visual aspect to information-sharing that both providers and patients found helpful as part of the contraceptive counselling process (Lee et al., 2021). Although visual aids or physical models are not alone sufficient to ensure that SDM occurs (Makoul & Clayman, 2006), they can assist with clarifying the contraceptive options and provide a visual guide to help understanding (Lee et al., 2021). This approach may be especially important for youth or any individuals who are first encountering the numerous options available for birth control (Lee et al., 2021). Ultimately, a layered approach which incorporates various aspects of tools or strategies into the decision-making process may be the most effective way for primary care providers to enact SDM in the contraceptive counselling process. Use of a variety of strategies to enhance SDM was part of Wackenhut et al.’s (2021) study, which also doubled as a quality-improvement project. Primary care clinics might similarly take on quality improvement projects to promote SDM, whether in contraceptive counselling or in other decision-making contexts. A 30 comprehensive SDM strategy might involve a combination of DAs or DSTs, such as implementing SOGC’s “It’s a Plan” prior to visits for contraceptive counselling along with the use of open-ended questions about patient goals and preferences to begin the conversation. Using physical aids during the appointment, as a visual supplement to the information being provided, could then assist in conveying the different available options. 31 Chapter Five: Conclusion This integrative review highlighted the value of SDM strategies and tools in enhancing the quality of contraceptive counseling in primary care and provided insight into the ways that primary care providers can use these tools or strategies in practice. SDM tools or strategies were associated with numerous positive outcomes, including increased patient satisfaction with counselling (Callegari et al., 2021), increased decision certainty (Korger et al., 2021), increased satisfaction with chosen contraceptive method (Dehlendorf et al., 2019), greater self-efficacy (Callegari et al., 2021), and improved contraceptive knowledge (Bitzer et al., 2021; Callegari et al., 2021; Dehlendorf et al., 201). However, variability in study design, definitions of SDM, and measurement tools complicated direct comparisons and generalizability. While decision aids and digital tools used prior to clinical encounters offered time-efficient support, collaborative conversation may still be necessary for SDM to take place (Callegari et al., 2021; Dehlendorf et al., 2019). Structured open-ended dialogue was found to foster deeper patient engagement, albeit with greater time demands placed on the provider (White et al., 2024). Effective implementation of SDM in contraceptive counselling may require an approach that incorporates different aspects of interventions prior to and during appointments. Limitations of this review included a restricted publication date range (2019–2024), which may have excluded relevant earlier work, and a narrowed focus on studies that assessed SDM through patient outcomes or perspectives in clinical settings. 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Ovid MEDLINE. https://www.wolterskluwer.com/en/solutions/ovid/ovid-medline-901 38 Appendix 1 Search Strategy Table 2. Search Terms and MESH Headings Concept CINAHL Medline OVID Search Terms Mesh Headings Search Terms Mesh Heading Shared decision (shared decision making making) or (shared decisionmaking) OR patient N2 (participat* or engagement or collaborat*) (MH "Patient Participation") OR (MH "Decision Making, Shared") (patient adj2 (participat* or engagement or collaborat*)) OR (shared decision making or shared decision-making) Decision Making, Shared/ OR Patient Participation/ Contraceptives (MH "Contraception") OR (MH "Hormonal Contraception") OR (MH "Ovulation Inhibition") OR (MH "Contraceptive Devices+") OR (MH "Contraceptive Agents+") (contracept* or birth control or intrauterine devices or condoms or norplan) OR exp Contraceptive Agents/ OR exp Contraceptive Devices/ OR contraception/ or contraception, barrier/ or hormonal contraception/ or ovulation inhibition/ contracept* or (birth control) or (intrauterine device) or condom* or norplan 39 Appendix 2 PRISMA Diagram Figure 1. PRISMA flow diagram Note. Flow chart adapted from “The Prisma 2020 statement: An updated guideline for reporting systematic reviews” by M. J. Page., J. E. McKenzie., P. M. Bossuyt, I. Boutron, T. C. Hoffmann, C. D. Mulrow, L. Shamseer, J. M. Tetzlaff, E. A. Akl, S. E. Brennan, R. Chou, J. Glanville, J. M. 40 Grimshaw, A. Hróbjartsson, M. M. Lalu, T. Li, E. W. Loder, E. Mayo-Wilson, S. McDonald… D. Moher, 2021, British Medical Journal, 372, n71. Copyright 2021 by BMJ Publishing Group Ltd. 41 Appendix 3 Integrative Literature Review Matrix Study Bitzer, J., Oppelt, P.G., & Deten, A. (2021). Evaluation of a patient-centred, needs-based approach to support shared decision making in contraceptive counselling: The COCO study. The European Journal of Contraception & Reproductive Health Care, 26(4), 326–333. https://doi.org/10.1080/13625187.2021.1908539 Study Purpose To assess whether a structured, needs-based contraceptive counselling approach improves decisionmaking, satisfaction, and contraceptive method selection. Study Design Observational study. Gynecologists were recruited to use the survey with women seeking contraceptive options in clinics. Outcomes were measured immediately post-intervention and at six-month follow-up. Eligibility Women aged 16-30 attending participating providers’ offices for contraceptive advice. Data Collection and Analysis Data was collected via questionnaire. Authors stated statistical analysis of descriptive and comparative data was completed by a third-party company. Intervention (Tool or Strategy) Needs-based structured questionnaire. Sample Size and Characteristics Providers: n = 92 (OB/GYN physicians), patients: n=1176 aged between 16 and 30 years. Mean age range of patients was 23 years. No other demographic information provided. Outcome Measures (1) Likert scale on gynecologist and patients’ thoughts and experiences of the survey, (2) which contraceptives methods were discussed, and (3) number of patients who switched contraceptive methods after counselling. Key Findings 72% of women reported overall satisfaction with counseling. Most physicians rated the usefulness of the survey as “good” (60%), whereas 68% of patients rated the survey as “very good”. Patients’ preference for LARC increased after intervention. Strengths Standardized approach, study conducted in a practice setting which increases applicability. Limitations No control group, lack of demographic information, potential selection bias, recall bias in 6-month follow-up, loss to follow-up at 6 months survey (only 145 women took part). Feasibility in Primary Care The length of time for the questionnaire is not specified, which could be a limiting factor. 42 Study Callegari, L. S., Nelson, K. M., Arterburn, D. E., Dehlendorf, C., Magnusson, S. L., Benson, S. K., Schwarz, E. B., & Borrero, S. (2021). Development and pilot testing of a patientcentered web-based reproductive decision support tool for primary care. Journal of General Internal Medicine, 36(10), 2989–2999. https://doi.org/10.1007/s11606-020-06506-6 Study Purpose Development and testing of “MyPath”, a decision support tool for women’s reproductive health, in Veterans Health Administration primary care. Study Design Non-randomized pilot study. Recruitment via telephone. Conducted over four months in control and intervention phase. Eligibility Women veterans aged 18-44 seeking contraceptive counselling at selected primary care clinics. Data Collection Analysis Pre- and post-visit surveys at appointment on iPads. Chi-squared testing was done for comparative outcomes, t-tests for pre- and post-visit variables, and comparative analysis for group categorical data. Intervention (Tool or Strategy) Use MyPath, a web-based interactive decision support tool used by patients before contraceptive counselling. Sample Size and Characteristics Providers: n=7 (6 physicians, 1 NP), patients: n= 58 aged 18 to 44. Intervention and control group selfreported ethnicity was white (53.3% and 46.4%), black (20% and 17.9%), Hispanic/Latina (6.7% and 3.6%) or other (20% and 32.1%). Outcome Measures (1) Likert scale for perception of intervention, (2) Interpersonal Quality of Family Planning (IQFP) scale, (3) Modified validated Perceived Efficacy in Patient Provider Interactions (PEPPI) scale, (4) Validated Decisional Conflict Scale, (5) Measure of Alignment of Choices (MATCH) scale, (6) reproductive knowledge and (7) pre-visit contraceptive choice vs. post-visit contraceptive choice. Key Findings Participants (83.3%) found the tool understandable and helpful. Providers (100%) agreed or strongly agreed the tool helped patients make informed decisions about contraceptives. Significant change in pre- to post appointment PEPPI scores and reproductive knowledge scores in the intervention group. Strengths Use of validated scales for measuring outcomes. Use of a control group. Although not randomized, demographic characteristics were similar among both groups. Limitations Not all participants discussed contraceptive options during the study. Small sample sizes were used, researchers planned to do a larger trial in the future. Feasibility in Primary Care MyPath took an average of 11 minutes to complete before appointments, which was considered acceptable. Given that the tool can be accessed online cost would unlikely be a barrier. 43 Study Dehlendorf, C., Fitzpatrick, J., Fox, E., Holt, K., Vittinghoff, E., Reed, R., Campora, M. P., Sokoloff, A., & Kuppermann, M. (2019). Cluster randomized trial of a patient-centered contraceptive decision support tool, My Birth Control. American Journal of Obstetrics and Gynecology, 220(6), 565-565. https://doi.org/10.1016/j.ajog.2019.02.015 Study Purpose Evaluate the influence of interactive DST My Birth Control when used before a provider visit for contraceptive treatment options Study Design Cluster randomized control trial. Participants were recruited in waiting rooms, randomized by provider and stratified based on clinical site. Follow up occurred at 4 and 7 months. Eligibility Age 15 to 45 years, not currently pregnant, not desiring pregnancy within 7 months, English or Spanish speaking, no previous interaction with My Birth Control tool. Data Collection and Analysis Data collected in person post-visit, then via phone or email at follow up. Analysis conducted using chisquared tests, multivariate mixed effects logistic regression and random effect models. Intervention (Tool or Strategy) Use of “My Birth Control” DST for approximately 10 minutes on an iPad immediately before visit. Sample Size and Characteristics Providers: n=28 (NPs, midwives, PAs and non-licensed health care professionals), patients: n=758 aged 15-49. Self-identified ethnicities reported by patients were Hispanic/Latina (38%), Asian or Pacific Islander (16%), African American/Black (10%) or White (23%). Outcome Measures (1) Continuation of chosen contraceptive method at 4 and 7 months (2) Interpersonal Quality of Family Planning scale (IQFP), (3) visit satisfaction and (4) Validated Decisional Conflict Scale, (5) knowledge of contraceptives pre- and post-visit and (6) chosen contraceptive method post-counselling. Key Findings No difference between control and intervention arms for: continuation of chosen method at 7 months, decisional conflict, overall satisfaction with provider interaction, satisfaction with method chosen or in use of a highly effective method (LARC). However, there was a significantly higher level of knowledge on contraceptives and of ratings of IQFP in the intervention group. Strengths Strengths included use of a control and intervention group, follow up surveyors were blinded to study arm and large sample size. Statistical analysis also did attempt to control for random effects of different providers. Patient characteristics were similar among control and intervention groups. Limitations Both control and intervention groups were 407 and 351 participants, respectively, and both lost around 40 participants to follow up, which may have influenced results. Feasibility in Primary Care The use of the tool and the appointments occur in a primary care setting and patients use the DST before the visit, allowing for efficiency. 44 Study Korger, S., Eggeling, M., Cress, U., Kimmerle, J., & Bientzle M. (2021). Decision aids to prepare patients for shared decision making: Two randomized controlled experiments on the impact of awareness of preference-sensitivity and personal motives. Health Expectations, 24(2), 257–268. https://doi.org/10.1111/hex.13159 Study Purpose To investigate the use of narrative (patient testimonial) or non-narrative (written explanation) DAs which explain preference sensitivity and personal motives to support shared decision making (SDM). Study Design Randomized control trial. University students were recruited via email. Instead of a provider appointment, participants were presented with a hypothetical scenario then asked whether they would choose an IUD over OC. Eligibility Females aged 18 to 35 and current use of OCs. Any medical professionals were excluded. Data Collection and Analysis Pre- and post-test surveys were used for data collection. Analyses of variance (ANOVA), mixedmultivariate analyses of variance (MANOVA) and Bonferroni-corrected post-hoc tests. Intervention (Tool or Strategy) Before simulated contraceptive counselling, participants were presented with a text with either a testimonial of patient decision-making (narrative intervention group) or non-narrative decision-making strategies (non-narrative intervention group). Sample Size and Characteristics Providers: none, patients/participants: n=238, with a mean age of 23 years. Age range unknown. No additional demographic information provided. Outcome Measures Researchers measured preparation and evaluation of decision making and decisional certainty. Exploratory data was collected regarding motives. Key Findings Compared to control, non-narrative and narrative groups reported significantly higher preparedness for decision-making. Participants in the control group also reported significantly lower decision certainty, decision satisfaction and positive evaluation of decision than both intervention groups. Strengths Randomization and use of control group, and heterogeneity of sample as well as interventions within groups increases validity of findings. Limitations Participants were not actually seeking reproductive health care and not interacting with actual providers therefore potentially decreasing applicability of the findings in the practice setting. Feasibility in Primary Care The texts used in the appointment were specific to the choice between OC and copper IUD therefore further work would be required to adapt the strategy to other decisional contexts. 45 Study Lee, S. Y., Brodyn, A. L., Koppel, R. S., Tyler, C. P., Geppert, A. A., Truehart, A. I., & Gilliam, M. L. (2021). Provider and patient perspectives on a new tangible decision aid tool to support patientcentered contraceptive counseling with adolescents and young adults. Journal of Pediatric and Adolescent Gynecology, 34(1), 18–25. https://doi.org/10.1016/j.jpag.2020.10.004 Study Purpose To describe the design and implementation of a tangible decision aid for shared decision making in contraceptive counselling. Study Design Mixed-methods design. Providers were recruited via e-mail and in person. Patients were recruited by medical office staff and nurses at time of appointments. Eligibility Aged 12 to 29 years old attending the participating providers’ clinic for contraceptive counselling. Data Collection and Analysis Quantitative data was collected from participating patients immediately after the appointment. Descriptive statistics were analyzed using Microsoft excel. Qualitative data was organized into themes by one researcher. Intervention (Tool or Strategy) Use of a physical model of contraceptive options, including a pill pack, male and female condoms, hormonal implant, IUD, copper IUD, patch, and hormonal ring, during contraceptive counselling. Sample Size and Characteristics Providers: n=10 (7 OB/GYN physicians, 3 NPs, and 2 OB/GYN physician assistants), patients: n=40 aged 15 to 29. Self-identified ethnicities of patients were Black/African American (32.5%), Asian or Asian American (24%), White (17.5%) or Hispanic/Latina (12.5%). Outcome Measures (1) A brief quantitative survey post-appointment on the usability and acceptability of the tool and (2) whether they left the appointment with a contraceptive method. Providers completed semi structured qualitative interviews around their thoughts and impressions after using the tool. Key Findings Total of 95% of patient participants found the tool helpful in deciding on a contraceptive method. The visual aspect of the tool was appreciated by 92% of patients. Providers found the tool helped shift the conversation towards a shared approach and helped accelerate conversations in appointments. Strengths Use in practice increases external validity. Findings are enhanced by incorporation of both the provider and patient perspective. Limitations Small sample size. Limited data collected from patient participants. Less standardized approach to counselling (use of tool was the only requirement) reduces internal validity. Feasibility in Primary Care The tool required minimal training for providers, and did not appear to add significant workload or time to appointments, therefore would be feasible to implement in the primary care setting. 46 Study Wackenhut, J. S., Ellis, A. L., Pridgen, K. H., & Shorten, A. (2021). Structured contraceptive counseling with shared decision making: Effects of implementation at a university student health and wellness clinic. Women’s Healthcare: A Clinical Journal for NPs, 9(1), 45–48. https://doi.org/10.51256/whc022106 Study Purpose Design, implement and evaluate a contraceptive counselling protocol using an SDM framework in a university health clinic Study Design Quality improvement project and a pre-/post-test study. Recruitment via email. Retrospective baseline data was collected from patients with contraceptive counselling appointments prior to project implementation (pre-test) and surveys were conducted following project implementation (post-test). Eligibility Students were considered eligible if enrolled at the university and had a contraceptive counselling appointment within the prior 12 months or during the project. Data Collection and Analysis Data collected through emailed surveys. No description of statistical analysis. Intervention (Tool or Strategy) Staff training on shared decision making, educational videos on contraceptives provided to patients, tiered contraceptive effectiveness chart to use in counselling sessions. Sample Size and Characteristics Providers: n=7 (6 NPs and 3 physicians), patients: n=53 (age range unknown). No other demographic information provided. Outcome Measures Patient satisfaction surveys with contraceptive counselling were not described in detail in the study. Surveys on experience were also sent to providers during project implementation. Key Findings Most satisfaction outcomes increased in surveys post-test compared to baseline, however only adequacy of information received during the visit was rated significantly higher in the intervention group (P=0.31). Providers found that the project made the counselling process easier (p=0.34). Strengths Use of a comparison group in the same clinic. Both provider and patient perspectives were considered. Limitations Students in the baseline study group could have recall bias as their appointments could have been anytime over the last 12 months. Additionally, there were only half as many students who participated in the post-test group. Limited description of statistical analysis, outcome measures, or results. Feasibility in Primary Care Although the findings of this study lack clarity and external validity, the range of strategies used to support SDM in the primary care setting addresses both pre-appointment and during appointment stages of the decision-making process, which could provide greater support for SDM. 47 Study White, K. O., Treder, K. M., Fico, P., Raskin, E., & Lerner, N. M. (2024). Development and evaluation of a novel approach to patient-centered contraceptive counseling. Women’s Health Issues, 34(5), 473–479. https://doi.org/10.1016/j.whi.2024.06.003 Study Purpose Develop a contraceptive counselling tool for shared decision making called PHI CARE, then implement with patients and perform a qualitative study to measure the tool’s acceptability. Study Design Qualitative study. Participants willing to undergo a contraceptive counselling session were recruited via convenience sampling through the clinic, statewide contraceptive programs and social media. Patients met with the provider for counselling via telehealth. Eligibility Age 18 years or over with experience using contraception to prevent pregnancy and seeking contraceptive counselling from a provider. Also access to online video conference. Data Collection and Analysis Surveys were conducted over zoom immediately after the counselling sessions. Qualitative data analysis was done concurrently with interviews, participants were recruited until researchers reached thematic saturations. The transcripts were independently coded by two trained researchers. Intervention (Tool or Strategy) Use of PHI CARE tool for contraceptive counselling, an open-ended questionnaire to elicit preferences and needs for contraception. Sample Size and Characteristics Providers: n=1 (OB/GYN physician), patients: n=12 aged 23 to 28. Patients’ self-identified ethnicity was Black (59%), White (33%), or Asian (8%). Outcome Measures The answers were open-ended and asked about the impression, flow and content of the counselling sessions. Themes and subthemes were uncovered in qualitative analysis. Key Findings Participants found the interactions more positive when compared to previous contraceptive counselling. A major theme was the shift of the locus of control from the provider to the patient. Another was empowerment, and autonomy. Participants appreciated being able to share what was important to them. Strengths Authors were clear about the contents of the counselling, which suggests that intervention was standardized among participants thus improving internal validity. Limitations Participants were recruited outside of their usual medical care on the basis that they would be willing to undergo contraceptive counselling, but were not actually seeking contraceptive counselling, which could compromise external validity. Relevance to Research Question (Feasibility) The counselling sessions themselves took an average of 22 minutes, which for primary care visits may not always be feasible, especially if the patient has multiple issues to discuss in a visit.